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PATHOLOGICAL    RESEARCHES 


O  N 


PHTHISIS. 


DR.    CLARKE    ON    PHTHISIS. 

"  We  cannot  conclude  this  section  without  expressing  our  obligations  to  M. 
Louis  the  able  author  of  the  "  Traité  de  la  Phtiiisie."  We  are  so  much 
indebted  lo  this  zealous  and  indefatigable  physician  for  all  our  more  precise 
knowledge  of  the  pathological  anatomy  of  Phthisis,  that  we  think  it  due  to  him  to 
acknowledo-e  the  great  assistance  we  have  derived  from  his  researches  in  the  com- 
position of  this  article  ;  and  we  beg  to  refer  our  readers  for  more  full  informa- 
tion to  his  treatise,  as  they  will  not  only  find  therein  the  best  account  of  the  mor- 
bid anatomy  and  symptoms  of  the  disease,  but  will  moreover  learn  to  admire,  and 
perhaps  to  imitate,  the  industry,  the  zeal,  and  the  scrupulous  veracity  of  this 
most  accurate  and  philosophical  observer." — Cyclop.  Pract.  Med.  Part  xxii. 
p.  306. 

"  M.  Louis  certainly  ranks  as  the  first  physician  of  France  and  probably  of 
Europe."  —  Marshall  Hall. 


PATHOLOGICAL    RESEARCHES 


PHTHISIS. 


By    p.    CH. 

Doctor  in  Medicine  of  tlie  Faculties   of 

Hospita)  of  La  Pitié  ;  President  for  Lifa 

Member  of  the  Royal  Academy  of  medi(Sne  ;  Correspondenrtf  the  Royal 
Academy  of  Marseilles,  of  the  Imperial  Medico-Chirurgical  Academy 
of  St.  Petersburgh,  and  of  the  Royal  Medical  Society  of  Edin- 
burgh, Member  of  the  Legion  of  Honor. 


TRANSLATED      FROM     THE      FRENCH, 

WITH  INTRODUCTION,  NOTES,  ADDITIONS,   AND  AN 
ESSAY  ON    TREATMENT. 

By    CHARLES    COWAN, 

M.  D.,  E.  M.  D.,  P.  M,  R.  C.  S.,  E. 

Member  of  the  Society  tor  Medical  Observation  ;   Bachelier  en-Lettres   of  the  Sorbonne; 

Elève  of  the  Hospitals  of  Paris  and  of  the  Ecole  Praclique  ;  Ex-President  of  the 

Hunlerian  Society,  and  Member  of  the  Royal  Medical  and  Ethical 

Societies  of  Edinburgh. 


REVISED      AND      ALTERED 


By    henry    I.    BOWDITCH,    M.    D. 

Fellow  of  the    Massachusetts  Medical  Society  and  Member  of  the  Society  for    Medical 
Observation  at  Paris. 


BOSTON HILLIARD,   GRAY    AND    CO 

1836. 


ill  ^ 


(X/\/^^ — ■ 


(^VV^_^^    ] 


Entered  according  to  the  Act  of  Congress,  in  the  year  1836,  by 

Henry    I.    Bowditch, 

In  the  Clerk's  Ofl&ce  of  the  District  Court  of  the  District  of  Massachusetts- 


BOSTON, 
PRINTED     BY    1.    R. 


WILLIAM    STOKES,   M.  D. 

PHYSICIAN     TO   THE    MEATH     HOSPITAL, 

PROFESSOR  OF  CLINICAL  MEDICINE, 

&c.        &c.        &c. 
AND 

HENRY    RILEY,    M.  D. 

PHYSICIAN     TO    THE     BRISTOL     INFIRMARY, 
LICENTIATE  OF  THE  ROYAL  COLLEGE  OF  PHYSICIANS, 

&c.        &c.        &c. 

PROM   THEIR    GRATEFULLY    OBLIGED    FRIEND, 

THE    TRANSLATOR 


CONTENTS 


American  Editor's  Preface, xxi 

Translator's  Introduction, xxv 

Author's  preface, Ixi 


PART   I. 
PATHOLOGICAL    ANATOMY 


CHAPTER    I. 

Respiratory  Organs,          .                 ....  3 

Art.  I.  Of  the  Lungs, ib. 

Obs.  L  Tubercular  Cavity,  including  three-fourths  of  the  Right 

Lung,             16 

Obs.  IL  Mass  of   organized  Fibrin  filling  a  moderately  sized 

Tubercular  Excavation, 22 


vin  CONTENTS. 

Obs.  III.  Healthy  Fragment  of  Pulmonary  Parenchyma,  unat- 
tached, in  the  midst  of  an  Excavation,            .        .  27 

State  of  the  Bronchia, 36 

Acute  Inflammation  of  the  Substance  of  the  Lungs  in  the 

last  stage  of  Phthisis, 37 

Acute  Inflammation  towards  the  close  of  other  Chronic  Dis- 
eases,   38 

Art.  II.  Of  the  Pleurae,            .......  39 

Adhesions  of  the  Pleuree  in  Phthisis,    ....  ib. 

"         in  cases  fatal  from  other  Diseases,            .         .  41 
Acute   Pleurisy  towards  the   close  of  Phthisis   and  other 

Chronic  Affections, 42 

Art.  III.  Of  the  Epiglottis,  Larynx  and  Trachea,             .         .  ib. 

Sec.  1.  Ulcerations  of  the  Trachea,           ....  43 

2.  «             "       Larynx, 46 

3.  "            "       Epiglottis,        ....  ib. 
State  of  these  Organs  in  Subjects  dead  from  other  Chronic 

Diseases,        ........  48 

CHAPTER    II. 

Organs  o"^  Circulation,            49 

Art.  I.  Of  the  Heart  and  Pericardium,         ....  ib. 

State  of  the  Heart  in  other  Chronic  Diseases,           .         .  52 

Art.  II.  Of  the  Aorta, ib. 

State  of  the  Aorta  in  other  Chronic     iseases,                    .  54 

CHAPTER    III. 

Digestive  Organs, ^  57 

Art.  I.  Of  the  Pharynx  and  Œsophagus,        .        .        .        .  ib. 

State  ofthc.se  Organs  in  other  Chronic  Diseases,          .  58 


PATHOLOGICAL    ANATOMY.  IX 

Art.  II.  Stomach, 59 

Sec.  1.  Of  the  Volume  and  Situation  of  the  Stomach,        .  ib. 

"  "  "  "  "  in  other 

Chronic  Diseases, ib. 

Sec.  2.  Softening  with  diminished  Thickness  of  the  Mucous 

Membrane  of  the  Stomach,  ....  60 

Sec.  3.  Redness  combined  with  thickening,  with  a  Mamillated 
State  or  Softening  of  the  Mucous  Membrane,  and 
occurring  in  the  anterior  portion  of  the  Stomach,  64 

Sec.  4.  Redness    with  Softening  of  the  Mucous  Membrane 

lining  the  great  Cul-de-sac  of  the  Stomach,         .  65 

Sec.  5.  The  mamillated  appearance  and  greyish  color  of  the 

Mucous  Membrane  of  the  Stomach,  .  .  .  67 
Sec.  6.  Ulcerations  of  the  Mucous  Membrane  of  the  Stomach,  68 
Sec,  7.  Some  other  morbid  changes  of  the  Mucous  Membrane 

of  the  Stomach, 69 

Tabular  View  of  the  different  Lesions  of  the  Gastric  Mucous 

Membrane,  ..>.....  70 

Tabular  View  of  the  different  Lesions  of  the  Gastric  Mucous 

Membrane  in  other  Diseases,  ....         71 

Art.  III.  Of  the  Duodenum, 72 

IV.  Of  the  Small  Intestine,      .        ...        .        .        .        73 

Sec.  1.  Of  the  Mucous  Membrane  of  the  Small  Intestine  in  its 

healthy  state, 74 

Sc  2.  Pat  hology  of  the  Small  Intestine,      ....        78 
Obs.  IV.  Large  Intestinal  Ulcerations,  Perforation  of  the  Small 

Intestine, 84 

State'of  the^Sraall  Intestine  in  other  Chronic  Diseases,  90 

Art.  V.  Large  Intestine, 91 

State  of  the  Large  Intestine  after  other  Chronic  Diseases,       99 

2 


X  CONTENTS. 

CHAPTERIV. 

Lymphatic  Glands, 99 

Art.  r.  Of  the  Mesenteric  Glands, 100 

II.  Of  the  Mesocascal,  Mesocolic,  and  Lumbar  Glands,  104 

III.  Of  the  Cervical,  Axillary  and  Bronchial  Glands,       .  105 

State  of  the  Lymphatic  Glands  after  other  Chronic  Diseases,  106 

CHAPTER    V. 

Biliary  Apparatus,         . 107 

Art.  I.  Of  the  Liver,          ........  ib. 

State  of  the  Liver  after  other  Chronic  Diseases,     .        .  108 

Art.  II.  Of  the  Bile  and  Gail-Bladder,       ....  112 

State  of  the  Bile  and  Gall-Bladder  after  other  Chronic  Dis- 
eases,             114 

CHAPTER  VI. 

Spleen, 114 

State  of  the  Spleen  after  other  Chronic  Diseases,        .  116 

CHAPTER    VII. 

Urinary  Organs, 117 

Obs.  V.  Tubercular  Matter  in  the   Right  Kidney  and  corres- 
ponding Ureter, 118 

In  other  Diseases, 121 

CHAPTER   VIII. 

Genital  Organs,          .                .....  122 

Art.  I.  Of  the  Male  Genital  Organs,     .        .        ,        .        ..  ib 


PATHOLOGICAL    ANATOMY.  XI 

Ob  S.  VI.  Tubercular  Matter  in  the  Prostate,  Vesiculse,  and  Vas 

Deferens,  122 

State  of  the  Male  Genital  Organs   after  other  Acute  or 

Chronic  Diseases, J 28 

Art.  II.  Of  the  Female  Genital  Organs,  .        ;         .  129 

State  of  the  Female  Genital  Organs  after  other  Chronic 

Diseases, 130 

CHAPTER    IX. 

Peritoneum, 130 

Obs.  VII.  A  thick  layer  of  the  Tubercular  and  Grey,  Semi- 
transparent  Matter  in  the  Epiploon  and  Mesocolon,       ib. 
State  of  the  Peritoneum  after  other  Chronic  Diseases,  138 

CHAPTER    X. 

Brain  and  its  Membranes, 139 

State  after  other  Chronic  Diseases,      ....  142 

Obs,  VIII.  Hydatids  in  the  upper  part  of  the  Brain,       .         .  145 

IX.  Tubercles  in  the  Cerebrum  and  Cerebellum,     .  151 

Summary, 157 


XII  CONTENTS. 


PART    II. 

SYMPTOMS. 


CHAPTER    I. 

Symptoms  of  Phthisis, 165 

Table  of  the  duration  of  Phthisis,         ....  J69 

Cough, 171 

Expectoration, ib. 

Hsemoptysis,            176 

Obs.  X.  Copious  Haemoptysis  unsuccessfully  treated  by  Bleed- 
ing,             179 

Dyspnœa, 185 

Pain 186 

Fever, 189 

Sudamina,            193 

Thirst,             . 194 

Appetite, ib. 

Diarrhoea, J95 

Emaciation, J99 

Face,  &c., 201 


SYMPTOMS.  XUl 


CHAPTER    II. 


Diagnosis,      .........  201 

Diagnosis  of  the  first  period  of  Phthisis,  .        .        .        202 

Obs.  X.  (bis).  Phthisis  recognised  the  seventeenth  day  from  its 

invasion,  205 

Diagnosis  of  the  second  period  of  Phthisis,      ,         .         .         210 
Obs.  XL  Bronchial  Dilatation  in  the  summit  of  the  Lungs  mis- 
taken for  a  Tuberculous  Excavation,        .        ,  212 

CHAPTER    III. 

Pneumonia    and    Pleurisy   occurring    shortly    before 

DEATH, 217 

CHAPTER    IV. 

Symptoms   of  Ulcerations  of   the  Epiglottis,  Larynx 

AND  Trachea, 219 

Art.  I.  Symptoms  of  Ulcerations  of  the  Epiglottis,  .  ib. 

Obs.  XIL  Ulcerations  of  the  Epiglottis  unaccompanied  by  those 

of  the  Larynx  and  Trachea,  ....        220 

X  in.  Complete  destruction  of  the  Epiglottis,       .         .  225 

XIV.  Deep  Ulcerations  of  the  Epiglottis  and  Larynx,  230 

Art.  II.  Symptoms  of  Ulcerated  Larynx,  .        .        .  237 

III.  Symptoms  of  Ulcerated  Trachea,     ....         239 

Obs.  XV.  Large  Ulcerations  of  the  Trachea.     Symptoms  very 

indistinct, 240 

XVI.  Extensive  and  deep  Ulcerations  of  the  Trachea. 
Destruction  of  portions  of  the  Cartilaginous  Rings. 
No  Symptoms, 246 


XIV  CONTENTS. 

Inflammation  of  the  Lining  Membrane  of  the  Trachea  with- 
,  out  Ulceration, 252 

CHAPTER    V. 

Symptoms  of  the  various  alterations  of  the  Gastric 

Mucous  Membrane,  253 

Art.  I.  Symptoms  of  Softening  with  diminished  Thickness  of 

the  Mucous  Membrane  of  the  Stomach,  .  254 

Ob&.  XVII,  Predominance  of  Gastric  Symptoms,  .         .        256 

Art.  II.  Symptoms   of   Inflammation    of    tlie     Mucous   Mem- 
brane of  the  Stomach  when   limited  to  its  anterior 

surface, 263 

Obs.  XVIII.  Strongly  marked  Gastric  Symptoms,  .         .        264 

Art.  III.  Symptoms  observed  when  the  Mucous  Membrane  of 
the  Stomach   is  red  and  softened  in  the  great  Cul- 
de-sac,      ...  ....  270 

Obs.  XIX.  Few  and  slightly  marked  Gastric  Symptoms,         .        271 
Art.  IV.  Symptoms  of  Simple  Ulcerations  of  the  Gastric  Mucous 

Membrane, 275 

Obs.  XX.  Rather  prominent  Gastric  Symptoms,  ,         .  ib. 

State  of  the  Digestive  Functions  when  the  Gastric  Mucous 
Membrane  was  Mamillated  and  Greyish,  also  when 

it  was  perfectly  sound, 280 

Summary  of  the  four  preceding  Sections,       .        .        .        .        281 
Obs.  XXI.  Incomplete   Cicatrix  of  the  Gastric  Mucous  Mem- 
brane,         283 

XXII.  Transformation  of  a  portion  of  the  Muscular  Coat 

into  a  Semi- cartilaginous  Substance,  .        .        286 

Art.  V.  State  of  the  Tongue,  .....  293 

Obs.  XXIII.  Tongue  of  a  deep  red,   at  first  moist,  afterwards 

dry.     Gastric  Mucous  Membrane  healthy,  ..        294 


SYMPTOMS.  XV 


CHAPTER    VI. 

Functions  of  the  Genital  Organs,    .         .         .        .  302 

Art.  I.  Generative  Functions  in  Men,           ,         .         .         .  ib. 

n.            «                  «       in  Women,         ...  303 

CHAPTER    VII. 

Cerebral  Symptoms, 306 

Obs.  XXIV.  Ventricular  Arachnitis.     Symptoms  prominent,  ib. 
XXV.  Circumscribed     Sub-arachnoidean     Inflammation  ; 

partial  softening  of  the  Brain,            .         .         .  311 

XXVI.  Partial  softening  of  the  Brain,     ....  315. 

CHAPTER    VIII. 

Varieties  ■which  Phthisis  presents  in  its  Progress,  318 
Obs.  XXVII.  Phthisis  latent  during  Twelve  Months,          .  319 
XXVIII.        "          "          "       Eight          "           .        .  322 
XXIX.        «           "           "       Thirty         "        .         .  327 
XXX.        "          "        very  chronic,  overlooked,         .  333 
XXXI.        «          "        Encysted  Tubercles,     .        .  340 
XXXI  t.        "          "        Tuberculous  Patches  between  Per- 
itoneal False  Membranes,      ....  345 
Summary  of  the  six  preceding  Observations,           .        .  349 

Acute  Phthisis, 352 

Obs.  XXXIII.  Phthisis  fatal  on  the  Thirty-fifth  day,     .        .  ib. 
XXXIV.  Acute   Phthisis.      Consecutive    Pneumonia  the 

cause  of  Death,            .....  357 


XVI  CONTENTS. 

XXXV.  Phthisis  Mal  in  Fifty  Days,            .        .  .        362 

^  XXXVI.        «          "     in  Forty-eight  Days,      .         .  368 

Summary  of  the  preceding  Observations,         .         .  .        372 

Obs.  XXXVII.  Phthisis  fatal  in  Thirty  Days,     ...  374 

CHAPTER    IX. 

Symptoms  of  Perforation  of  the  Lcng  by  Tuberculous 

Softening,      .......         379 

Obs.  XXXVIII.  Excavation  communicating  with  the  Pleurae  and 
Bronchia.  Death,  Thirty  Days  after  the  Per- 
foration,          ib. 

XXXIX.  Excavation   communicating  with  the  Pleurse, 
but  not  with  the  Bronchia.      Death,  Three 
Days  after  the  Perforation,      .        .        .        383 
XL.  Excavation  communicating  with  the  Pleurse  and 

Bronchia, 387 

XLI.  Excavation  communicating    with   the   Pleurse 
and  Bronchia.      Death,  Eighteen  days  after 
the  Perforation,  ....  390 

XLII.  Excavation  only  communicating  with  the  Pleu- 
rae.    Death,  Thirty-six  Hours  after  the  Per- 
foration, ......        394 

XLI  1 1.  Excavation  communicating  with  the  Pleurae  and 
Bronchia.     Death,  Twelve  Hours  after  the 

Perforation, 398 

Analysis  of  the  preceding  Observations,  .        '.        .        401 

Obs.  XLIV.  Excavation  communicating  with  the  Pleurae  and 

Bronchia.    Death,  Six  Days  after  the  Perforation,  4U3 
Continuation  of  the  Analysis, 407 


SYMPTOMS.  XVll 


CHAPTER    X. 

Sudden  Deaths, 414 

Art.  I.  Unexpected  Deaths,  which  may  be  explained  more  or 

less  plausibly  by  the  state  of  the  Organs  after  Death,    ib. 

Obs.  XLV., ib. 

XLVI.,            418 

Art.  I.  Sudden  Deaths,   -which  are  not  accounted  for  by  the 

post-mortem  appearances,          ....  422 

Obs.  XLVIL, ib. 

XLVIIL, 425 

XLIX., 429 

L., 433 

CHAPTER    XI. 

Causes  of  Phthisis,        .        .         .        .        .         .        .  437 

Influence  of  Sex, 438 

"          of  Pneumonia  and  Fleurisy,    ...  .  ib. 

"           of  EroncLitis, 441 

"          of  Dress,          .......  445 

Hereditary  Influence, 446 

Influence  of  Age, •  447 

CHAPTER    XII. 

Treatment,        .               448 


XVlll  CONTENTS. 


APPENDIX. 


Translator's  Appendix, 457 

A.  Origin  and  Development  of  Phthisis,      ...  ib. 

B.  Diagnosis  of  Phthisis,        ......  460 

C.  Influence  of  Sex  in  the  Production  of  Phthisis,  464 

D.  "        of  Pneumonia,           ....  466 

E.  "        of  Bronchitis, 467 

F.  «        of  Dress, 468 

G.  «        of  Age, 469 

"        of  Dust, 473 

"        of  Moisture, 477 

"        of  a  Dry  and  Hot  Atmosphere,           .        .  479 

"        of  Animal  Emanations,          ...  ib. 

«        of  Vegetable,        «            ....  480 

"        of  Mineral,             "        .        .         .        .  ib. 

"        of  Impure  Air, ib. 

"        of  Active  Life  in  Open  Air,            .        .  481 

"        of  Sedentary  Life   with   confined  posture  of 

the  Body, ib. 

Exercise  of  the  Vocal  Organs,     ....  482 

Influences  which  predispose  to  Phthisis,          .        .  483 

Preservative  Influences, 484 


SYMPTOMS.  XIX 


Influence  of  Climate, 484 


Contagion  of  PliLhisis, 


1'Y; 


Influence  of  Season,  .....  4f8 

H.  Essay  on  Treatment, 4?9 

American  Editor's  Appekdix, 5i3 


AMERICAN    EDITOR'S    PREFACE 


This  edition  of  Louis's  work  on  Phthisis  is  called  the  re- 
publication of  Dr.  Cowan's  translation,  and  such  it  substan- 
tially is.  Yet  I  should  feel  that  I  was  wanting  in  my  duty  as 
Editor,  did  I  not  make  the  following  statements.  There  are 
many  omissions  in  the  English  translation,  some  of  which  are 
not  very  important,  while  others  materially  alter  the  significa- 
tion of  the  original  work.  All  of  ^hese  have  been  supplied. 
Dr.  Cowan  has  also  fallen  into  some  errors.  These  statements 
are  mere  assertions  I  allow,  but  were  it  necessary,  I  could 
give  a  list  of  errata  ;  it  is  of  little  moment,  however,  for  me  to 
state  any  thing  farther  than  this,  that  the  re-publication  differs 
very  materially  from  the  English  translation. 

It  will  be  seen  that  I  have  placed  all  Dr.  Cowan's  additions 
ja  the  form  of  an  appendix,  instead  of  having  them  scattered 
in  various  parts  of  the  work.  Some  sections  of  this  appendix 
are  very  valuable,  as  for  example,  C,  D,  E  and  G.  These 
contain  the  analyses  of  facts  collected  by  such  men  as  Parent 
Duchatelet,  Benoiston-Chateauneauf,  hard  laborers  in  the 
cause  of  science,  and  who  never  lay  down  a  principle  without 
having  it  rest  upon  a  firm  foundation  of  facts.  These  sec- 
tions contain  likewise  summaries  of  valuable  memoirs  by  Dr. 
Lombard  of  Geneva,  he.     These  summaries  are  in  general 


XXll  AMERICAN    EDITOR  S    PREFACE. 

made  correctly,  but  in  one  case  there  are  so  many  dis- 
crepancies between  the  statements  of  Dr.  Cowan  and  the 
original  paper  of  Dr.  Lombard  (vide  page  472),  that  1  have 
found  it  impossible  to  correct  Dr.  Cowan's  remarks  without 
altering  the  whole  paragraph  or  omitting  it  altogether.  The 
Essay  on  Treatment,  H,  1  candidly  confess  I  should  have 
preferred  not  to  have  seen  appended  to  a  work  written  by 
Louis.  Let  me  be  understood.  I  do  not  doubt  that  many 
valuable  remarks  are  contained  therein,  for  where  is  there  any 
effort  of  the  human  mind  which  does  not  contain  some  truth? 
But  in  quoting,  as  Dr.  Cowan  has,  from  works  which  are 
written  as  differently  as  possible  from  the  strict  method  pur- 
sued by  Louis,  he  has  implied  that  he  himself  is  not  so  de- 
voted a  disciple  of  the  Numerical  School,  as  we  were  led  to 
expect  from  his  having  undertaken  to  translate  a  work  of 
this  kind. 

It  may  be  said  that  I  wish  to  excite  a  partisan  spirit  by  this 
remark.  Far  be  it  from  me  to  wish  for  sects  and  intolerance 
either  in  medicine  or  religion.  1  wish  to  see  one  boldly  express 
his  opinion  and  act  up  to  it.  It  is  the  peculiar  charm  of  the 
Numerical  School  that  it  Invites  all  to  become  laborers  to  ad- 
vance the  holy  cause  of  truth  ;  it  tells  all  that  if  they  will 
strictly  follow  its  rules  success  will  be  the  result.  It  teaches 
every  man  that  he  ought  not  to  consider  any  principle  ascertain 
which  has  not  been  proved.  Dr.  Cowan  quotes  from  many 
who  do  not  hold  this  maxim  to  be  true. 

I  have   given  in   this    re-publication   all   that  is  contained 

in  the  original  English  translation,  but  1  would  particu- 
larly invite  the  reader  to  judge  of  Louis's  method  as  it 
stands  developed  in  the  text,  and  after  his  decision  let  him 
peruse  all  the  addenda  in  which,  as  I  have  already  stated,  are 
some  valuable  principles,  and  very  many  important  facts. 


AMERICAN    EDITOR  S    PREFACE.  XXIU 

The  original  work  on  Phthisis  was  written  and  published 
before  that  on  Ty{)hus  was  commenced.  This  is  the  reason 
why  the  former  has  not  such  a  finished  aspect  as  the  latter. 
It  is  not,  in  fact,  so  philosophically  written  ;  the  Numerical 
Method  is  less  perfectly  displayed  in  it  than  in  the  two  vol- 
umes on  Typhus  ;  but  it  bears  upon  its  face,  as  the  whole  of 
Louis's  writings  do,  mathematical  exactness.  Need  1  say 
more  than  this  to  induce  any  lover  of  truth  to  peruse  this 
volume  attentively  ? 

It  will  depend  upon  the  reception  these  works  meet  with 
from  the  public,  whether  the  translation  of  the  remainder  of 
Louis's  writings  be  undertaken,  but  I  hope  ere  long  that  the 
whole  of  them,  which  have  not  yet  been  published  in  this 
country,  will  appear  in  the  present  shape. 


TRANSLATOR'S     INTRODUCTION.* 


"  The  foundation  of  all  knowledge  must  be  a  careful  and  extensive 
acquisition  o? facts  ;  and  the  first  duty  of  an  inquirer,  in  any  depart- 
ment of  science,  is  to  bind  himself  down  to  such  a  patitnt  accumula- 
tion, bewaring  of  all  premature  attempts  to  combine  and  generalize 
them."  —  Vide  Jlhercrombit  on  the  Intellect.  Powers,  page  375. 

"Ce  que  se  rattache  à  l'espèce  humaine,  considérée  en  masse,  est 
de  l'ordre  des  faits  physiques;  plus  le  nombre  des  individus  qu'on 
observe  est  grand,  plus  la  volonté  individuelle  s'efface  et  laisse  pré- 
dominer la  série  des  faits  généraux."  —  Quetelet  de  V  Influence  des 
Saisons  sur  VHomme.    Bruxelles,  1832, 

Whether  we  give  publicity  to  our  own  researches,  or 
become  the  means  of  disseminating  the  opinions  and  investi- 
gations of  others,  we  should  be  alike  actuated  by  a  conviction 

*  Since  much  of  the  information  scattered  through  the  course  of  this 
introduction,  respecting  the  author  and  the  method  he  has  pursued,  to  be 
correct,  must  have  required  pecuhar  opportunities,  the  translator  feels  call- 
ed upon  to  say,  that  he  has  spent  nearly  four  years  in  the  hospitals  of  Paris  ; 
that  he  assiduously  followed  the  visits,  post-mortems  and  lectures  of  M. 
Louis,  at  La  Pitié,  for  twelve  months  ;  that  he  has  been  honored  with  the 
private  intimacy  of  the  author,  and  by  his  kindness  inspected  the  tables  from 
which  the  present  volume  was  composed,  as  also  those  for  his  researches  on 
the  "  Affection  Typhoide."  These  various  sources  have  all  conspired  to  im- 
press him  with  a  deep  conviction  of  the  value  of  M.  Louis's  works  and 
method,  and  his  presenting  the  English  reader  with  the  present  volume  is  a 
simple  consequence  of  his  sincerity. 

4 


XXVI  TRANSLATOR  s    INTRODUCTION. 

of  their  utility  in  the  abstract,  the  want  of  further  information, 
and  a  conscientious  impression  that  the  facts  they  embody 
are  the  literal  transcript  of  realities,  and  not  the  distorted  or 
partial  materials  so  easily  accumulated  for  the  support  of  a 
theory  or  the  making  prevalent  individual  opinion.  At  a 
moment  like  the  present,  when  books  are  daily  teeming  from 
the  press  in  almost  every  department  of  medical  science,  any 
useless  addition  to  their  number  ought  scrupulously  to  be 
avoided  ;  for  both  time  and  intellect  are  wasted  in  the  discrim- 
ination of  what  is  worthless  or  mere  repetition,  instead  of  being 
occupied  in  the  acquirement  of  what  really  forms  an  increase 
to  the  knowledge  we  already  possess.  In  the  more  positive 
sciences,  the  evil  alluded  to  is  less  sensibly  felt,  the  greater 
precision  of  the  principles  on  which  they  are  founded,  limiting 
the  field  for  speculation,  by  giving  a  necessary  convergence  to 
faithfully  detailed  phenomena,  and  at  the  same  time  acting  as 
guides  for  the  rejection  of  inaccurate  imperfect  description,  or 
hasty  ill-digested  induction. 

Medicine,  for  many  very  evident  reasons,  has  been  and 
continues  to  be  the  victim  of  varied  and  contradictory  hypoth- 
eses :  —  the  minds  of  all  who  have  attempted  to  trace  its 
deviating  course,  have  wearied  in  the  vague  conflict  of  opin- 
ions, and  have  either  sheltered  themselves  under  the  authority 
of  a  name,  or  satisfied  their  doubts  by  the  creation  of  a  prin- 
ciple quite  as  hypothetical  and  uncertain  as  any  by  which 
they  were  previously  bewildered.  This  favored  progeny  of 
their  fancy,  like  colored  media  to  the  vision,  soon  tinges  all 
intellectual  combinations,  and  falsifies  the  very  evidence  of  the 
senses  ;  facts  seem  to  multiply  in  its  support,  and  what  at 
first  was  regarded  as  probable,  soon  strengthens  with  the  fond 
hope  of  discovery  and  the  assent  of  eager,  uninquiring  enthu- 
siasts, becoming  the  basis  of  a  system  from  which  dissent 


TRANSLATOR  s    INTRODUCTION.  XXVll 

involves  error,  and  opposing  facts  are  either  overlooked  or 
discredited.  With  such  a  mental  bias,  the  very  talents  and 
researches  of  an  individual  become  injurious  to  a  profession  he 
would  otherwise  have  adorned,  and  how  often  in  looking  back 
over  the  history  of  medicine,  can  we  see,  as  it  were,  our  pro- 
gress arrested  by  some  favorite  dogma  of  a  powerful  but  preju- 
diced mind,  until  a  rival  intellect  lays  bare  the  fallacy,  erects 
another  in  its  stead,  changing  little  more  than  the  name  of 
what  it  thought  to  have  annihilated.  The  "  Sohdists,"  the 
"  Fluidlsts,"  the  "  Brownists,"  the  "  Cullenists,"  and  the 
"  Broussaists,"  with  many  others,  have  undoubtedly  ob- 
structed the  path  of  rigorous  and  impartial  observation,  by 
limiting  the  wide  field  of  philosophic  inquiry  to  the  too  often 
forced  adaptation  of  facts  calculated  to  support  their  own 
peculiar  and  almost  necessarily  imperfect  conceptions  :  and 
although  their  labors  have  not  been  fruitless,  and  much  posi- 
tive knowledge  may  be  gleaned  from  the  mass  of  their  inves- 
tigations, who  does  not  feel  that  its  volume  has  been  infinitely 
lessened,  and  its  value  impaired,  by  the  pre-existence  of  a 
principle  it  was  intended  to  establish,  rather  than  eliminate? 
The  ease  with  which  a  theory  may  be  proposed  and  support- 
ed, is  exactly  proportionate  to  the  vagueness  of  our  knowledge, 
to  the  absence  of  impartial  incontestable  facts;  and  until  the 
latter  have  enjoyed  that  natural  precedence  which  has  been 
granted  them  in  every  science  that  deserves  the  name,  our 
deductions  can  never  be  established  upon  any  satisfactory  and 
lasting  foundation.  Could  genius  grasp  the  bearings  of  those 
laws  which  influence  the  health  and  modify  the  diseases  of 
organized  beings,  still,  observation  would  be  necessary  to  test 
the  truth  or  falsehood  of  its  inspirations,  but  from  the  finite 
nature  and  contracted  limits  of  the  human  faculties,  the  neces- 
sity of  observation  if  not  more  absolute  is  at  least  more  glaring, 


XXVIU  TRANSLATORS    INTRODUCTION. 

and  the  conviction  of  our  mental  feebleness  should  make  us 
shrink  from  all  hasty  precocious  generalization. 

Let  the  candid  inquirer  contemplate  the  mass  of  crude 
amorphous  materials  which  ages  have  accumulated  ;  let  him 
glance  over  those  creeds  of  medical  infallibility  which  have 
successively  risen  and  waned  in  the  opinion  of  mankind  ;  then 
let  him  direct  his  view  to  the  living  representatives  of  systems 
either  stamped  with  antiquity,  or  attractive  by  their  modern 
freshness  and  apparent  novelty,  and  what  are  the  conclusions 
he  must  form  ?  Let  him  change  his  locality  and  he  changes 
his  principles,  while  every  where /act?  are  their  reputed  founda- 
tions. The  pure  antiphlogistics  of  the  French,  the  contro 
stimulantsof  the  Italians,  the  omœopathic  of  the  Germans,  and 
the  hepatic  nostrums  of  England,  all  lay  claims  to  his  atten- 
tion, and  are  all  recommended  as  the  fruits  of  long  experience 
and  multiplied  observation.  The  discovery  of  truth  from  such 
conflicting  testimonies,  if  possible,  is  at  least  a  Herculean  task, 
and  he  either  becomes  the  bigoted  partisan  of  a  sect,  or  what 
is  far  more  rarely  the  case,  resolved  to  have  recourse  to  rigor- 
ous impartial  inquiry.  The  results  of  his  labors  may  indeed 
be  unsatisfactory,  and  must  necessarily  embrace  but  a  limited 
portion  of  the  vast  field  of  medical  investigation,  he  will,  how- 
ever, ensure  the  satisfaction  of  collecting  materials  available 
to  others,  and  have  sacrificed  the  desire  of  ephemeral  reputa- 
tion, to  the  far  higher  motive  of  being  really  useful.  It  is 
indeed  a  subject  of  deep  congratulation,  that  minds  such  as 
these  are  daily  multiplying,  and  in  looking  back  on  what  a 
few  years  have  effected,  there  is  every  encouragement  for 
future  anticipation,  and  every  reason  to  suppose,  that  the 
results  to  which  we  shall  ultimately  arrive,  though  probably 
never  of  any  Utopian  character,  will  at  least  commend  them- 
selves to  the  reception  of  every  sound  and  unprejudiced  mind. 


TRANSLATOR  s    INTRODUCTION.  XXIX 

What  names,  we  would  ask,  continue  to  survive  the  oblivious 
tendency  of  time  ?  The  detailers  and  chroniclers  of  facts  not 
opinions  ;  the  latter  have  long  "  sunk  into  the  abyss  of  forget- 
fulness,  and  truth  alone  swims  over  the  vast  extent  of  ages." 

Our  author  presents  an  interesting  example  of  the  effect 
produced  upon  the  mind,  by  the  contemplation  of  the  uncer- 
tain nature  of  much  of  our  medical  knowledge  ;  and  he  is  also 
an  illustrious  proof  of  what  the  exertions  of  a  single  individual 
can  effect,  when,  unfettered  by  theory  or  system,  they  are 
steadily  directed  to  the  simple  unbiassed  observation  of  facts. 
M.  Louis,  from  the  age  of  seventeen  to  thirty-three,  studied 
and  practised  medicine  in  Russia  with  considerable  success. 
Gifted  with  a  naturally  active  and  inquiring  mind,  the  mul- 
titude of  opinions  contrasted  with  the  paucity  of  facts,  could 
not  fail  to  create  great  dissatisfaction  and  uncertainty  as  to  the 
validity  of  many  of  the  principles  most  generally  admitted, 
and  on  which  much  of  our  practice  was  founded. 

Accidental  circumstances  at  the  close  of  this  period  bring- 
ing him  to  Paris,  he  soon  became  acquainted  with  and  eagerly 
studied  the  writings  of  the  celebrated  Broussais,  at  the  same 
time  assiduously  following  that  distinguished  pathologist,  both 
in  the  hospital  and  lecture  room.  The  impression  produced 
upon  his  mind  by  this  direction  of  his  studies,  was,  that  while 
M.  Broussais  evidently  proved  others  to  be  wrong,  he  was 
very  far  from  demonstrating  himself  to  be  right  ;  that  while  he 
rendered  palpable  the  doubts  which  might  reasonably  be  en- 
tertained respecting  many  of  our  present  principles,  he  had 
failed  to  substitute  any  thing  more  satisfactory  in  their  place. 
From  this  moment  M.  Louis  resolved  to  devote  himself  ex- 
clusively to  observation,  solely  actuated  by  a  desire  to  relieve 
oppressive  doubt  and  uncertainty,  and  with  no  intention  of 
ever  giving  publicity  to  his  labors.     He  at  once  decided  on 


XXX  TRANSLATOR  s    INTRODUCTION. 

remaining  at  Paris,  as  affording  the  best  opportunities  for 
prosecuting  his  intentions,  and  entered  the  hospital  of  La 
Charité  as  a  clinical  c/er/:,  under  his  friend  Professor  Chomel. 
For  nearly  seven  years,  including  the  flower  of  his  bodily  and 
mental  powers  (from  the  age  of  thirty-three  to  forty),  he  con- 
secrated the  whole  of  his  time  and  talents  to  rigorous  impar- 
tial observation.  All  private  practice  was  relinquished,  and 
he  allowed  no  considerations  of  personal  emolument  to  inter- 
fere with  the  resolution  he  had  formed.  For  some  time  his 
extreme  minuteness  of  inquiry  and  accuracy  of  description, 
were  the  subjects  of  sneering  and  ridicule,  and  cui  bono  was 
not  unfrequently  and  tauntingly  asked.  The  absence  of  any 
immediate  result  seemed  for  a  time  to  justify  their  contempt 
of  a  method  involving  too  much  labor  and  personal  sacrifice  to 
be  generally  popular  or  easily  imitated;  and  M.  Louis  him- 
self, at  moments,  almost  yielded  to  the  increasing  difficulties 
of  the  task  he  had  undertaken.  No  sooner,  however,  were 
his  facts  sufficiently  numerous  to  admit  of  numerical  analysis, 
than  all  doubt  and  hesitation  were  dissipated,  and  the  convic- 
tion, that  the  path  he  was  pursuing  could  alone  conduct  him 
to  the  discovery  of  truth,  became  the  animating  motive  for 
future  perseverance.  Many  of  the  results  to  which  he  arrived 
soon  attracted  general  attention,  and  among  those  who  had 
formerly  derided  his  method  while  they  admired  his  zeal,  he 
found  many  to  applaud  and  a  few  to  imitate.  From  this  mo- 
ment may  be  dated,  the  presence  of  that  strong  impression  of 
the  necessity  of  exact  observation,  by  which  the  school  of 
Paris  has  been  since  so  distinguished,  and  which  is  now  grad- 
ually pervading  the  medical  institutions  of  the  continent  and 
our  own  country  :  it  is  undoubtedly  to  the  author  of  the  pres- 
ent volume,  that  we  ought  to  ascribe  the  practical  revival  of 
that  system,  which  had  for  ages  been  verbally  recognised  but 


TRANSLATOR  s    INTRODUCTION.  XXXI 

never  before  rigorously  exemplified.  For  the  last  five  years 
he  has  been  physician  to  the  hospital  of  La  Pitié  ;  the  num- 
ber of  advanced  students  (principally  English,  American,  and 
German),  who  follow  his  visits  and  clinical  lectures,  are  the 
best  testimonies  to  the  indefatigable  zeal  and  talent  with 
which  he  still  pursues  his  investigations,  and,  contrasted  with 
the  now  deserted  wards  of  M.  Broussais,  forms  a  practical 
illustration  of  the  striking  change  which  has  been  effected  in 
the  spirit  of  medical  inquiry. 

With  no  preconceived  views  of  his  own  to  establish  (and 
we  believe,  no  one  who  has^  will  observe  seven  years  !)  all 
results  from  such  researches  cannot  fail  to  address  themselves 
to  our  confidence,  and  in  the  present  instance  they  have  not 
only  the  additional  value  of  having  been  made  at  a  period  of 
life  when  the  judgment  is  matured  and  fancy  regulated,  but 
by  one  who,  so  to  speak,  began  his  studies  after  several  years 
practical  experience  of  their  difficulties.  He  regarded  each 
individual  example  of  disease,  as  a  problem  which  could  only 
be  solved  by  patient  and  exact  observation  ;  with  this  convic- 
tion, he  studied  all  the  functions  during  life,  from  the  com- 
mencement of  the  disease  to  its  termination  ;  for  the  same 
reason  he  examined  all  the  organs  after  death  ;  and  when 
attempting  to  arrive  at  any  general  conclusion,  he  not  only 
analyzed  the  facts  he  had  collected  relative  to  that  disease,  but 
submitted  them  to  a  rigorous  comparison  with  other  diseases 
which  were  at  all  analogous.  It  is  evidently  one  thing  to 
determine  the  series  of  symptoms,  or  alterations  of  structure, 
which  are  present  in  any  particular  affection,  and  another  to 
discover  what  symptoms  or  alterations  are  special  and  char- 
acteristic :  the  one  is  obtained  by  confining  ourselves  to  the 
disease  itself;  the  other  can  alone  result  from  comparison. 
A  very  short  time  was  sufficient  to  make  the  discovery  that 


XXXU  TRANSLATOR  S    INTRODUCTION. 

observation  was  immensely  difficult,  a  fact  which  authors 
hav.e  hitherto  overlooked,  thus  plainly  proving  that  they  them- 
selves observed  incompletely.  The  power  of  correct  obser- 
vation is  not  the  attribute  of  ignorance,  but  is  ceteris  paribus, 
always  proportionate  to  the  knowledge  the  individual  pos- 
sesses. With  what  additional  profit  and  success  does  the 
painter,  the  sculptor,  the  naturalist,  observe  after  a  long  cul- 
tivation of  their  respective  arts,  and  how  numerous  are  the 
details  detected,  which  would  wholly  escape  the  unpractised 
novice  ?  Now,  if  an  accurate  conception  of  external  char- 
acters, when  passive  under  the  eye  of  the  observer,  demands 
long  and  patient  exercise  for  its  acquirement,  how  much 
greater  must  be  the  difficulties  surrounding  the  complicated 
machine  of  the  human  frame,  under  all  the  varied  influences 
and  the  innumerable  modifications  of  which  it  is  susceptible  ? 
The  phenomena  are  not  only  complex  and  ever  varying,  but 
they  must  often  be  examined  through  the  distorting  medium 
of  a  suffering  and  fanciful  mind,  and  are  frequently  described 
with  the  intention  to  mislead  and  deceive.  Not  to  be  con- 
tinually the  dupe  of  such  sources  of  fallacy  (and  the  most 
practised  do  not  always  escape),  requires  long  habit  and  ex- 
tensive general  knowledge,  and  no  one  can  have  apprenticed 
himself,  as  the  author  in  his  preface  remarks,  to  the  trade  of 
minute  and  rigorous  observation,  without  a  deep  conviction  of 
the  difficulties  attending  it  and  the  necessity  of  long  continued 
perseverance. 

We  are  the  more  anxious  to  insist  on  the  great  difficulty 
and  infinite  importance  of  observation  in  medicine,  since  the 
very  impression  is  an  element  of  success,  and  of  that  caution 
we  should  never  be  free  from,  in  the  accumulation  of  facts,  by 
which  our  own  opinions  and  those  of  others  are  to  be  regu- 
lated.    The  general  habits  of  our  schools  and  hospitals  render 


TRANSLATOR  s    INTRODUCTION.  XXXIU 

the  warning  still  more  necessary  ;  for  while  observation  is 
nominally  recommended  to  the  student,  and  even  sometimes 
pursued  with  zeal  and  partial  success  in  the  first  years  of  his 
medical  studies,  it  is  too  often  thrown  aside  with  the  character 
of  student,  at  a  moment  when  he  is  just  beginning  to  acquire 
the  power  of  observing  correctly.  The  very  fact  that  the 
task  is,  in  the  majority  of  instances,  imposed  upon  those  just 
entering  their  career,  is  calculated  to  impress  the  mind  with  a 
very  imperfect  and  insufficient  idea  of  its  importance.  The 
student  should  be  taught  as  well  as  allowed  to  observe,  and 
the  results  of  his  first  attempts  exposed  to  the  strict  scrutiny 
of  a  master,  who  has  not  himself  relinquished  the  occupation. 
He  should  be  habituated  to  analyze  and  compare  the  cases  he 
has  collected  :  the  time  and  attention  necessary  for  even  a 
small  number  of  facts,  to  reduce  them  to  order  and  trace 
their  relations,  would  convince  him  of  the  difficulties  he  at 
first  little  anticipated,  and  at  the  same  time  impress  him  with 
the  importance  of  the  results  a  more  extensive  and  correct 
application  of  the  method  would  insure. 

The  advice  of  the  illustrious  Sydenham  on  the  principles 
which  should  guide  the  observer,  should  never  be  forgotten. 
"In  writing,"  he  says,  "  the  history  of  diseases,  every  philo- 
sophical hypothesis  which  has  prepossessed  the  writer  in  its 
favor,  ought  to  be  totally  laid  aside,  and  then  the  manifest 
and  natural  phenomena  of  diseases,  however  minute,  must  be 
noted  with  the  utmost  accuracy."  We  should  indeed  never 
replace  description  by  opinion,*  or  employ  words  and  expres- 

*  "  Appearances  should  always  be  described  in  terms  which  involve  no 
opinion  as  to  their  causes.  These  are  the  objects  of  separate  examination, 
and  will  be  best  understood  if  the  facts  are  given  fairly,  without  any  depend- 
ence on  what  should  yet  be  considered  unknown  ;  this  rule  is  very  essential 
where  the  facts  are  in  a  certain  degree  complicated." — Dugald  Stewart. 

5 


XXXÏV  TRANSLATOR  S    INTRODUCTION. 

siens,  the  meaning  of  which  is  not  definite,  but  might  be  inter- 
preted to  coincide  with  the  peculiarities  of  individual  opinion. 
"  Temperament,"  "  pneumonic  sputa,"  "  catarrhal  expecto- 
ration," "  marked  febrile  movement,"  "  healthy  state  of  the 
digestive  tube,"  and  an  infinity  of  other  expressions,  should 
never  be  substituted  for  the  simple  description  of  what  w& 
include  by  the  terms.  The  value  of  particular  phrases  is 
relative,  and  liable  to  vary  with  the  daily  progress  of  science  ; 
their  real  meaning  can  only  be  surmised  by  reference  to  the 
prevalent  opinions  of  the  time.  The  observer  should  always 
recollect  that  the  reader  has  no  means  to  judge  of  his  skill, 
but  in  proportion  to  the  minuteness  and  precision  of  his  de- 
scriptions ;  this  observation  should  be  sufficiently  complete  to 
enable  a  stranger  to  understand  and  employ  it,  the  language 
should  be  clear  and  concise,  and  in  all  enumeration  of  details, 
the  talent  of  saying  a  great  deal  in  a  few  words  should  be 
assiduously  cultivated.  The  want  of  attention  to  this  rule, 
renders  the  perusal  of  the  great  majority  of  observations  irk- 
some and  fatiguing.  Lastly,  let  him  never  forget,  that  mere 
opinions  and  unsupported  conclusions  cannot  be  admitted  as 
additions  to  our  knowledge,  until  they  have  again  been  ex- 
posed to  the  searching  ordeal  of  facts  ;  while,  faithful  descrip- 
tion, can  never  cease  to  be  valuable,  however  absurd  the 
hypothesis  it  may  have  tended  to  establish. 

But  observation,  however  extended  and  exact,  is  of  itself 
insufficient  to  generate  conclusions,  for,  collected  as  our  facts 
must  have  been,  through  a  series  of  months  or  years,  and  con- 
sisting of  an  infinite  variety  of  details,  no  memory  could  recall 
and  no  mind  could  grasp  their  complicated  relation  with  each 
other.  To  accomplish  this,  the  "  numerical  method"  is  neces- 
sary, that  is,  counting  the  number  of  all  the  individual  facts, 


TRANSLATOR  s    INTRODUCTION.  XXXV 

comparing  their  relative  frequency  in  cases  of  a  particular 
class,  and  then  determining  their  real  value,  by  a  comparison 
with  facts  of  other  classes,  which  have  also  been  reduced  to 
similar  elements.  This  is  the  plan  pursued  by  our  author,  and 
which  must  be  adopted  by  all  who  would  seek  to  establish 
truth  and  arrive  at  general  results.  Hitherto  we  have  satisfied 
ourselves  with  the  authority  of  experience,  and  its  currency 
in  medicine  is  such,  that  any  distinct  definition  of  its  value  has 
scarcely  been  attempted.  But  let  us  inquire  what  is  really 
included  by  experience  ?  Is  it  not  the  expression  of  the  con- 
clusions of  the  mind  upon  one  or  more  subjects  to  which  the 
attention  has  been  habitually  directed  ?  Is  it  not,  simply,  the 
final  impression  produced  by  a  review  of  the  past  ?  If  the  dis- 
covery of  truth  be  its  tendency,  why  has  individual  experience 
been  hitherto  so  discordant?  The  answer  is  easy.  In  a 
science  like  medicine,  where  the  difficulties  of  observation  are 
so  great,  and  the  objects  to  be  observed  so  numerous,  where 
theories  bias,  and  individual  peculiarities  necessarily  exert 
their  influence,  nearly  all,  if  not  all  the  conclusions  of  mere 
experience  are  varying  and  fallacious.  Who  does  not  feel 
himself  naturally  inclined  to  study  one  class  of  affections  more 
than  another,  to  be  arrested  by  particular  symptoms,  to  be 
more  interested  with  facts,  which  apparently  coincide  with 
some  favorite  views  he  has  either  adopted  from  others,  or 
insensibly  formed  during  the  course  of  his  studies  ?  How 
strongly  all  extraordinary  facts  and  what  we  call  interesting 
cases,  are  engraven  upon  the  mind,  and  forever  prominent  in 
the  retrospect,  while  the  great  mass  of  ordinarij  and,  conse- 
quently, important  occurrences  are  overlooked  and  forgotten  ? 
Some  unhoped  for  success  attending  the  means  we  employ, 
how  firmly  has  it  associated  the  cure  of  the  disease  with  the 


XXXVl  TRANSLATOR  s    INTRODUCTION. 

specific  nature  of  the  remedy,  and  how  easily  do  we  admit  as 
a  fact,  what  the  observation  of  another  proves  to  be  the  mere 
expression  of  coincidence  ?  Every  practitioner  has  his  pecu- 
liar therapeutics,  his  favorite  dogmas  to  support,  and  successes 
to  boast  ;  and  when  we  reflect  on  the  innumerable  opinions 
which  exist  on  all  complicated  subjects,  where  conclusions  are 
founded  on  the  materials  of  unrecorded  individual  experience, 
materials,  which  opportunity,  education,  and  a  thousand  acci- 
dental circumstances  are  forever  modifying  ;  we  cannot,  I 
think,  be  surprised  that  the  results  of  experience  in  medicine, 
have  not  been  more  uniform  and  satisfactory.  While  anxious 
to  impress  upon  the  reader  our  conviction  that  unrecorded 
experience  can  never  become  the  corner  stone  of  any  science 
whatever,  we  admit  that  it  has  justly  acquired,  in  a  few  rare 
instances,  unusual  relative  value  from  the  capacious  intellect 
and  retentive  memory  of  some  highly  favored  minds. 

Devoted  as  we  have  described  our  author  to  have  been  to 
the  observation  of  facts,  and  divested  as  he  was,  from  the 
very  state  of  mind  which  actuated  him  to  the  course  he  so 
undeviatingly  pursued,  from  all  ^preconceived  ojpinions,  yet  it 
was  impossible  that,  during  so  long  a  period  of  time,  his  mind 
should  not  have  been  unequally  impressed  by  the  phenomena 
before  him,  and  have  unknowingly  fixed  some  in  its  remem- 
brance to  the  exclusion  of  others,  instinctively  allotting  them 
a  relative  value,  and  arranging  them  to  favor  some  à  priori 
conclusions.  Now  no  circumstances  could  possibly  have  been 
more  favorable  to  test  the  value  of  experience,  than  those  in 
which  M.  Louis  was  placed  ;  yet,  when  at  the  close  of  his 
labors,  he  submitted  all  his  facts  to  the  unerring  test  of  arith- 
metical analysis,  in  every  instance,  were  the  à  priori  conclu- 
sionSf  which  he  had  formed  from  the  recollection  of  his  own 


TRANSLATOR  s    INTRODUCTION.  XXXVU 

facts,  found  to  he  erroneous.*  This  most  remarkable  result 
ought  to  be  indelibly  engraven  on  the  mind  of  every  observer, 
and  inspire  a  doubt  as  to  the  validity,  not  only  of  the  experi- 
ence of  others,  but  of  what  he  has  hitherto  perhaps  considered 
almost  infallible,  Ms  own. 

If  science  consist  of  laws  which  are  the  expressions  of  facts, 
what  course  ought  we  to  adopt  for  the  purpose  of  arriving  at 
those  laws  ?  Undoubtedly  one  which  leads  to  the  discovery  of 
the  relations  of  our  facts,  their  differences,  and  the  amount  of 
those  differences  ;  for,  a  law  is  only  a  formula  expressing  in 
definite  terms  the  value  of  a  constant  relation  existing  between 
a  certain  class  of  facts.  This  can  only  be  effected  by  the 
numerical  or  tabular  method,  against  which  much  ridicule  has 
been  directed,  but  on  which  every  positive  increase  of  our 
medical  knowledge  must  be  founded.  M.  Louis  does  not 
pretend  to  be  its  discoverer,  but  he  is  fairly  entitled  to  the 
merit,  of  having  been  the  first  who  has  rigorously  and  exten- 
sively applied  it  to  medicine. 

We  shall  briefly  describe  some  of  its  most  distinguishing 
features.  The  numerical  analysis  requires  in  the  first  place,  a 
sufficient  number  of  carefully  collected  facts  on  the  same  sub- 
ject j  our  object  is  then  to  classify  their  corresponding  ele- 
ments, so  that  not  only  are  all  the  details  of  those  facts  suc- 
cessively submitted  to  the  mind,  but  thoir  relative  frequency 
and  value  more  easily  estimated.  To  effect  this,  synoptical 
tables  are  indispensable,  and  their  number  necessarily  propor- 
tionate to  the  complex  nature  of  the  facts  we  are  analysing. 
Each  organ,  for  instance,  must  have  a  separate  column,  which 

*  "  Quand  je  me  suis  fait  une  idée,  à  priori,  des  faits  non  encore  analysés, 
j'ai  toujours  vu,  après  cette  analyse,  que  mon  idée,  à  priori,  était  fajtsse.^' — 
Letter  addressed  to  the  Translator  from  the  Author,  June  23,  1834. 


XXXviii  TRANSLATOR  s    INTRODUCTION. 

includes  its  description  in  every  case  we  intend  to  make  use 
of,  adopting  as  nearly  as  possible  similar  terms  for  similar 
conditions. 

This,  however,  alone  would  be  very  inefficient,  as  in  a  com- 
plicated structure  like  the  lungs,  where  so  many  alterations 
may  occur,  a  long  series  of  minute  description  would  defy 
analysis  from  simple  inspection  ;  each  organ,  therefore,  in  its 
turn,  becomes  the  subject  of  a  separate  table,  which  also  con- 
sists of  subdivisions  proportionably  numerous  as  the  object  we 
examine  is  simple  or  complex.  When  we  have  thus  arranged 
all  the  elements  of  our  facts,  we  compare  the  results  of  our 
different  columns  with  each  other,  having  it  thus  in  our  power 
to  view  them  in  their  various  relations,  while  we  may  at  plea- 
sure refer  particular  facts  to  their  respective  observations,  the 
same  number  accompanying  all  the  details  which  are  scattered 
through  a  variety  of  tables. 

It  will  be  remembered  there  is  nothing  arbitrary  in  this 
mode  of  proceeding,  nothing  left  to  individual  caprice  or  pre- 
conception ;  for,  in  the  arrangement  of  our  tables  we  perform 
a  purely  mechanical  operation,  indiscriminately  putting  down 
all  the  facts  in  their  respective  columns,  without  any  reference 
to  the  conclusions  to  which  they  ultimately  tend.  The  cor- 
rectness then,  of  any  opinions  we  may  form,  is  confirmed  or 
rejected  by  a  test  over  which  we  have  no  control,  and  the 
evidence  of  which  no  well-regulated  mind  can  resist,  while 
not  only  the  relative  importance  of  many  facts  to  which  our 
attention  had  been  less  distinctly  directed,  or  which  we  had 
wholly  forgotten,  is  forced  upon  our  consideration,  but  we  are 
also  led  to  the  discovery  of  what  we  have  only  casually  or 
incompletely  described. 

It  will  at  once  be  perceived  that  certain  laws,  require  for 
their  elucidation,  a  much  larger  number  of  examples  than 


TRANSLATOR  s    INTRODUCTION.  XXXlX 

Others  :  where  a  hundred  observations  may  in  one  case  be 
sufficient,  three  times  that  number  may  be  required  under 
other  circumstances.  Indeed,  as  a  general  rule,  the  more 
complicated  the  objects  we  examine,  the  greater  the  number 
of  facts  necessary  to  establish  our  conclusions  ;  for  the  same 
elements  not  being  repeated  in  all,  their  relative  aggregate 
number  must  vary,  and  their  real  value  can  only  be  estimated 
by  tracing  them  through  a  larger  number  of  analogous  in- 
stances. Were  we,  for  example,  analysing  one  hundred  cases 
of  pleurisy,  the  value  of  any  symptom  invariably  observed 
would  be  considerable,  and  perhaps  sufficiently  established  ; 
but,  were  it  only  present  twenty  times  out  of  that  hundred, 
its  real  importance  would  be  much  less  positive  and  require 
an  additional  number  of  facts  for  its  determination.* 

For  the  appreciation  of  treatment,  the  necessity  for  numer- 
ous facts  is  peculiarly  apparent,  for  though  a  hundred  cases 
would  be  valuable  evidence  in  favor  of  any  one  system  of 

*  The  translator,  as  it  seems  tome,  is  in  error  when  he  asserts  that  the  value 
of  a  symptom  which  occurs  only  twenty  times  in  a  hundred  cases  is  less  posi- 
tive than  that  which  invariably  occurs.  It  may  be  of  less  value,  I  allow,  in 
the  history  of  the  disease,  and  may  not  give  us  so  much  aid  in  the  treatment, 
but  its  value,  though  less  in  degree,  is  just  as  positive  as  the  symptom 
which  occurs  every  time.  A  part  is  less  than  a  whole,  its  value  is  less,  but 
our  ideas  attached  to  it  are  as  positive  as  those  attached  to  the  whole.  How 
comes  this  error  of  the  translator  ?  I  cannot  account  for  it  save  on  the  sup- 
position that  for  a  moment  he  forgot  one  grand  point  of  the  numerical  method 
as  pursued  by  Louis,  viz.  that  in  analysing  an  observation,  a  symptom  must 
not  be  supposed  to  be  present  or  absent  unless  the  presence  or  absence  of 
such  symptom  be  stated  in  the  original  notes  of  the  case.  Had  not  this 
point  been  momentarily  overlooked,  I  think  the  error  would  not  have  arisen, 
for  it  is  perfectly  evident,  that  if,  for  example,  in  a  hundred  cases  there  be 
found  pain  in  the  side  in  all,  and  pain  in  the  head  in  twenty,  while  in  the 
eighty  that  remain  there  is  no  pain  in  the  head,  it  is  evident  that  the  re- 
sult for  one  symptom  is  just  as  positive  as  for  the  other.  —  H.  I.  B. 


xl  translator's  introduction. 

cure,  it  is  only  by  comparison  with  others  that  its  real  efficacy 
can- be  decided.  There  are  also  other  sources  of  fallacy  which 
must  not  be  overlooked  ;  such  as  the  severity  of  the  disease, 
the  age  and  sex  of  the  patient,  the  state  of  health  at  the  time; 
the  natural  duration  of  the  affection,  the  epidemic  influences 
which  may  be  present,  &c.  ;  these  are  all  questions  to  be 
solved  before  we  can  arrive  at  any  positive  results.  From 
these  rapid  reflections,  we  may  form  some  idea  of  the  numer- 
ous difficulties  which  surround  every  question  of  therapeutics, 
and  feel  the  necessity  of  exercising  the  greatest  caution  in  ascri- 
bing any  definite  value  to  a  remedy  before  we  have  well  deter- 
mined, by  numerously  analysed  facts,  the  exact  circumstances 
under  which  its  action  has  proved  to  be  beneficial.*     No  part 


*  "  Nothing  eminent  can  be  done  in  the'  prognostic  and  especially  in  the 
curative  part  of  physic,  without  a»  accurate  and  circumstantial  history  of 
diseases  ;  for  how  is  it  possible  to  foretell  what  will  happen  in  a  distemper, 
and  proceed  properly  in  the  cure,  if  we  are  ignorant  of  the  constant  and  for- 
tuitous circumstances  attending  it,  and  the  general  progress  of  it  from  the 
beginning  to  the  end,  when  nothing  intervenes  to  obstruct  its  ordinary 
course,  whether  from  mismanagement,  accident,  or  otherwise  ?"  —  (Vide 
Sydenham.     Swan's  Edition,  page  9  —  note  of  the  editor.) 

"  There  will  never  be  any  great  and  considerable  advance  in  the  art  of 
healing,  till  all  hypothesis  and  mechanical  reasoning  are  out  of  vogue,  and 
till  men  are  come  about  again  to  the  ancient  method  of  pure  experiment, 
and  the  common  obvious  reasoning  entire  from  thence,"  &c.^  "  Not  a  single 
medicine  has  been  discovered  by  hypotheses  since  the  introduction  of  them 
into  physic,  about  two  thousand  years  ago,  nor  have  they  let  in  the  least 
light  into  the  affivir  of  administering  medicines  properly  in  particular  cir- 
cumstances, but  rather  served  to  bewilder  us,  to  perplex  practice,  and  create 
disputes,  which  are  never  to  he  decided  without  having  recourse  to  experi- 
ence, the  true  test  oj  opinions  in  physic."  To  experience  the  author  at- 
taches a  very  different  idea  from  the  general  acceptation.  He  evidently 
refers  to  recorded  experience,  or  the  tabular  method. — Vide  Bishop  Brown's 
Procedure  oJ  the  Human  Understanding,  pages  200—205.)    Sydenham,  in 


translator's  introduction.  xli 

of  medical  knowledge  is  more  in  want  of  some  rigorous  method 
of  investigation  than  that  of  therapeutics,  and  this  must  ever 
be  the  case,  until  a  system  analogous  to  the  one  we  have 
briefly  described  shall  be  generally  adopted. 

It  is  not  our  intention,  in  advocating  the  numerical  method, 
to  conceal  for  a  moment  its  difficulties  ;  these  are  great  and 
numerous,  but  at  the  same  time  they  can  never  form  any  solid 
argument  against  its  utility,  though  they  will  necessarily  curtail 
the  number  of  its  disciples.  It  is,  in  fact,  the  only  method  in 
our  power  to  pursue  ;  it  is  the  only  control  we  can  possess 
over  assertion,  the  only  test  for  opinion,  and  though  not  all  we 
can  wish,  and  no  doubt  will  ever  be  found  inadequate  for  the 
decision  of  many  questions,  yet  its  application  to  a  sufficient 
number  of  facts  must  inevitably  give  us  the  most  exact  and 
best  possible  knowledge  of  those  facts,  and  we  would  ask  the 
individual  who  believes  that  science  is  founded  upon  facts, 
what  more  he  would  require  ?  "  And  if,"  as  an  eloquent  and 
distinguished  writer  observes,  "  after  having  arrived  at  the  ter- 
mination of  extensive  labors,  the  hope  of  some  important  gen- 
eralization has  not  been  realized,  our  disappointment  may  find 
consolation  in  remembering  that  the  discovery  of  a  single  fact, 
well  observed,  well  described,  and  well  appreciated,  is  un- 
questionably an  advance  in  science,  while  ingenious  and  sedu- 
cing theories,  which  may  be  received  with  general  enthusiasm, 
are  of  often  nothing  more  than  a  retrograding."     But  should 

his  preface,  page  18,  says,  "  However,  I  do  not  deny,  but  that  the  physi- 
cian ought  to  attend  carefully  to  the  method  and  medicine  he  uses  in  curing 
diseases,  and  to  set  them  down  for  the  ease  of  his  memory,  as  well  as  the 
improvement  of  his  knowledge,  so  that  at  length,  after  many  years  experi- 
ence, he  may  fix  upon  such  a  method  of  curing  any  particular  disease,  as  he 
need  not  in  the  least  depart  from.^"  — Cowan. 

6 


xlii 


TRANSLATOR  s    INTRODUCTION. 


not  one  general  fact  result,  we  are  preparing  materials 
which  may  be  employed  by  those  who  succeed  us,  and  if 
their  accumulation  and  analysis  will  not  ultimately  extricate 
us  from  the  labyrinth  of  uncertainty  in  which  we  are  now 
straying,  we  may  regard  the  discovery  of  truth  as  a  vain  and 
hopeless  delusion. 

There  is  no  reason  for  the  expectation  on  which  many  seem 
to  rely,  that  a  master  mind  will  arise  and  dispel  the  darkness 
which  hitherto  has  defied  our  efforts  to  disperse,  for  "  in  the 
history  of  science,"  says  Sir  D.  Brewster,  "  we  see  no  exam- 
ple of  an  individual  mind  throwing  itself  far  in  advance  of  its 
contemporaries,  but  the  achievements  of  intellectual  power 
have  ever  been  the  result  of  combined  exertion.  The  powers 
of  analysis  and  combination  are  applied  to  the  humbler  labors 
of  observation  and  experiment,  and  in  the  ordeal  of  rival  in- 
quiry truth  is  purified  from  error."  Besides,  from  the  clear 
and  distinct  contemplation  of  numerous  facts,  unthought  of 
affinity  is  traced  and  unexpected  results  are  discovered  ; 
results  which  genius  could  never  have  foreseen,  or  hypothesis 
embraced  ;  for  while  their  existence  is  thus  demonstrated,  all 
clue  to  their  explanation  seems  lost. 

How  could  we  have  ascertained  that  tubercles  in  any  organ 
of  the  body,  after  the  age  of  fifteen,  involved  their  presence  in 
the  lungs  ?  That  phthisis  almost  invariably  commences  in  the 
upper  lobes  ?  That  it  is  more  frequent  in  women  than  in  men  ? 
That  pneumonia  is  more  easily  resolved  in  a  tuberculated 
than  in  a  healthy  lung  ?  That  simple  bronchitis  commences  at 
the  base  of  the  lungs,  pursuing  a  course  inverse  to  that  of 
phthisis  ?  That  chronic  peritonitis  indicates  pulmonary  tuber- 
cles ?  That  acute  affections,  when  free  from  complication,  are 
generally  confined  to  one  side  of  the  body,  or  one  part  of  an 
organ  if  single  ?    How  could  these  and  many  other  results,  be 


TRANSLATOR  s    INTRODUCTION.  XlllI 

obtained  but  by  rigorous  observation  and  numerical  analysis? 
And  what  theory  have  we  ever  heard  of,  which  could  have 
led  us  to  the  same  conclusions?  Had  they  been  advanced  as 
the  fruits  of  speculation,  how  absurd  some  of  them  would 
have  appeared,  and  their  very  announcement  would  have 
almost  ensured  their  rejection  ;  but  founded  as  they  are  on 
the  evidence  of  facts,  our  ignorance  of  the  laws  on  which  they 
depend  is  no  bar  to  their  practical  utility.  We  know  of  no 
considerations  more  directly  in  support  of  the  numerical 
method,  or  more  encouraging  to  all  who  have  the  necessary 
opportunity  and  perseverance  for  its  adoption,  than  this  almost 
spontaneous  creation  of  laws,  which  must  have  escaped  the 
sagacity  of  reasoning,  from  the  simple  fact,  that  when  demon- 
strated, they  refuse  to  coalesce  with  any  of  our  preconceived 
opinions. 

But  to  arrive  at  any  definite  and  characteristic  knowledge  of 
disease,  it  is  not  only  necessary  to  have  collected  numerous 
observations  and  exposed  them  to  a  rigorous  analysis,  but  to 
have  instituted  a  comparison  of  that  disease  with  all  others 
with  which  it  may  be  confounded,  for  the  purpose  of  arriving 
at  its  specific  and  distinguishing  features.  The  botanist  not 
only  collects  a  variety  of  plants,  and  by  strict  observation  of 
their  physical  characters,  groups  them  into  classes  and  families, 
but  by  careful  comparison  seeks  to  determine  those  peculiar- 
ities by  which  they  may  be  individually  distinguished.  The 
chemist,  the  comparative  anatomist,  follow  precisely  the  same 
plan,  and  in  medicine  we  see  it  exemplified  in  the  ever-vary- 
ing classifications  of  nosologists.  The  hitherto  imperfect  state 
of  our  pathological  knov/ledge  has  necessarily  included  that 
of  our  classsification  ;  the  latter  can  never  be  satisfactory  until 
it  may  be  regarded  as  the  ultimate  expression  of  our  facts, 
rather  than  a  prospective  attempt  at  generalization.      We 


xliv  translator's  introduction. 

would,  therefore,  particularly  direct  the  reader's  attention  to 
the  comparative  results  of  the  author,  and  when  he  reflects  that 
the  same  process  was  pursued  for  their  attainment  as  for  those 
of  the  principal  affection,  he  will  be  more  sensible  of  their 
value  and  more  capable  of  appreciating  the  time  and  labor 
comprehended  in  a  few  brief  lines. 

The  picture  we  have  drawn  of  the  obstacles  opposed  to  the 
successful  application  of  the  analytical  method,  is  not,  we  are 
aware,  calculated  to  ensure  popularity,   and  many  will  return 
to  the  less  laborious  and  less  responsible  opinion,  that  anything 
like  certainty  in  medicine  is  chimerical  ;  let  it,  however,  be 
remembered,  that  "  the  difficulty  of  acquiring  accurate  knowl- 
edge, is  an  admonition  of  nature,  which  reminds  man  of  his 
weakness,  and  the  caution  he  ought  to  observe,"  and  for  the 
encouragement  of  those  who  coincide  in  the  views  we  have 
expressed,  we  would  remark,  that  while  the  exertions  of  any 
one  individual  are  comparatively  insignificant,  yet  when  united 
with  those  of  others,  their  value  would  soon  be  apparent  ;  and 
we  feel  convinced,  that  the  labors  of  a  hundred  medical  men, 
strictly  undertaken  on  the  principles  we  have  advocated,  during 
a  period  of  twelve  months,  would  do  more  for  the  elucidation 
of  many  of  our  difficulties,  than  the  uncertain  materials  of  the 
last  two  thousand  years.     To  justify  this  assertion,   we  refer 
to  the  solitary  labors  of  M.  Louis,  whose  works  will  be  in- 
creasingly appreciated  with  the  progress  of  philosophical  in- 
vestigation, and  in  durability  and  value  will  long  survive  the 
ephemeral  productions  of  more  popular  but  theoretical  writers. 
The  state  of  every  department  of  science,  the  physical 
means  in  our  power  for  the  examination  of  disease,  are  all 
greatly  in  favor  of  success,  and  whenever  we  shall  be  in  pos- 
session of  a  sufficient  mass  of  unvarnished  facts,  there  are 
no  rational  grounds  to  suppose,  that  facts  in  medicine  will  not, 


translator's  introduction.  xlv 

to  a  certain  extent,  effect  what  they  have  invariably  done  in 
every  other  branch  of  human  knowledge  to  which  they  have 
been  impartially  applied. 

It  would  be  easy  to  enumerate  the  obstacles  which  oppose 
themselves  to  the  progress  of  medicine  ;  the  want  of  experi- 
ment (though  let  it  be  recollected  that  observation  and  ex- 
periment differ  rather  in  degree  than  in  land),  and  the  conse- 
quent difficulty  of  tracing  effects  to  their  true  causes  and  vice 
versa  ;  the  presence  of  casual  relations  from  which  we  cannot 
disencumber  our  facts  ;  the  influence  of  powers  which  modify 
the  phenomena  of  disease,  and  aid  or  counteract  the  action  of 
external  agents  ;  these  must  all  moderate  exaggerated  ex- 
pectation, and  render  a  long  series  of  observations  a  necessary 
preliminary  to  our  arriving  at  positive  results  ;  but  at  the  same 
time  they  cannot  be  adduced  as  arguments  against  the  only 
method  in  our  power  to  pursue  with  any  rational  hope  of 
success,  until  the  insufficiency  of  that  method  has  been  de- 
monstrated by  a  fair  and  unprejudiced  trial  :  —  this  has  not 
yet  been  done. 

It  cannot  be  objected  that  the  action  of  morbific  influences 
upon  the  frame  is  in  many  instances  not  regulated  by  definite 
or  deducihle  laws,  and  that  the  variations  of  diseases  are  such, 
as  to  defy  classification,  and  nullify  the  extension  of  our  con- 
clusions from  one  individual  to  another.  On  the  contrary,  all 
analogy  is  against  such  a  supposition,  and  the  little  that  has 
yet  been  done  is  equally  in  favor  of  an  opposite  inference. 
Is  there  no  correspondence  between  the  descriptions  of  Hippo- 
crates and  Aretœus,  and  what  we  are  observing  at  the  present 
moment  ?  Has  time,  has  climate,  has  civilization,  have  habits 
effaced  one  lineament  from  the  likeness  they  have  faithfully 
drawn  ?  It  is  only  when  the  objects  of  contemplation  are  few 
that  individual  varieties  seem  infinite,  and  as  we  never  could 


xlvi  translator's  introduction. 

have  deduced  the  spherical  figure  of  the  earth,  by  regarding 
the  inequaHties  of  the  surface  we  are  immediately  treading, 
but  which  from  a  higher  elevation  do  not  interfere  with  the 
grand  outline  characterising  the  whole,  so  in  medicine,  when- 
ever large  masses  of  facts  can  be  distinctly  unfolded  to  our 
view,  the  perplexing  individual  varieties  will  be  merged  in 
some  leading  predominant  features,  acting  as  guides  to  diag- 
nosis, and  forming  the  ground-work  of  therapeutical  indication. 

Admitting  this  to  be  the  case,  our  labors  and  the  number 
of  observations  required  cease  to  be  indefinite,  for  such  is  the 
uniformity  of  nature,  that  many  of  the  inductions  of  science 
stand  as  securely  on  the  foundation  of  a  comparatively  few 
well  observed  facts,  as  they  could  do  on  the  collected  obser- 
vations of  every  possible  individual  fact  of  which  they  are  in- 
tended to  be  the  expression. 

We  may  then,  without  any  enthusiasm,  suppose  that  this  in 
many  instances  would  be  the  case  in  medicine,  and  that  the 
comparative  results  of  a  very  few  individuals  would  give  satis- 
factory solutions  to  questions  which  are  now  unceasingly  re- 
examined and  solved,  to  suit  the  views  of  every  inquiring  and 
innovating  mind. 

The  last  few  years  have  been  unusually  fertile  in  the  accu- 
mulation of  accurately  described  facts,  but  scattered  as  they 
are  over  a  wide  surface,  they  are  necessarily  only  partially 
known,  and  their  aggregate  value  cannot  be  appreciated. 
An  immense  mass  of  knowledge  is,  therefore,  constantly  lying 
idle,  which,  if  properly  analysed,  would  frequently  embody 
results  by  which  much  useless  expenditure  of  time  and  talent 
would  be  avoided.  The  application  of  the  numerical  method 
to  the  facts  already  in  our  possession,  would  be  an  eminently 
useful  undertaking  ;  and  by  thus  deducing  the  history  of  dis- 


translator's  introduction.  xlvii 

eases,  we  should  make  an  inventory*  of  the  science,  and  be 
enabled  to  determine  the  amount  and  value  of  the  materials 
we  possess.  Did  we  only  succeed  in  demonstrating  the  pov- 
erty instead  of  the  riches  of  medicine,  we  should  at  least  have 
more  accurate  ideas  of  what  we  might  trust  to,  and  a  more 
certain  criterion  of  what  in  future  may  be  expected. f  Such 
a  survey  (Douglas)  would  advance  medicine  by  the  very  act 
of  its  being  made  ;  the  very  stirring  up  of  all  its  parts  would 
conduce  to  their  future  productiveness,  as  the  mere  turning 
up  of  the  soil  augments  its  fertility  and  adds  to  the  plenty  of 
the  ensuing  harvest.  Medicine,  while  it  was  surveyed,  would 
be  unintentionally  enriched,  and  seeds  that  had  long  remained 
dormant  in  it,  being  brought  to  light,  would  immediately  veg- 
etate. What  was  already  acquired  would  gain  in  value  ;  and 
the  line  would  be  clear  and  defined  from  which  others  must 
depart  to  obtain  fresh  accessions.! 

*  "  Few  works  of  labor  would  be  more  conducive  to  farther  advancement 
than  a  calendar,  resembling  an  inventory  of  the  state  of  man,  of  all  the  in- 
ventions which  are  now  extant,  out  of  which  doth  naturally  result  a  note, 
what  things  are  yet  held  impossible  or  not  invented."  —  Bacon. 

t  This  suggestion_has  been  acted  upon  by  M.  Chaponière,  in  his  inaugu- 
ral thesis  at  Paris,  June,  1832,  entitled  Essai  sw  les  Causes  et  le  Siège  des 
JVevralgies  de  la  Face.  The  author  spent  several  months  in  collecting  all 
the  observations  he  could  find  in  the  extensive  library  of  the  school  and 
from  other  sources.  He  could  only  avail  himself  of  two  hundred  and  fifty- 
three,  having  rejected  more  than  four  hundred,  which  contained  little  ex- 
cept the  diagnosis,  and  often  did  not  specify  the  sex.  TV^hile  regretting  the 
few  satisfactory  conclusions  to  be  drawn  from  his  analysis,  he  attributed  his 
failure  entirely  to  the  inexactitude  of  his  materials,  and  not  to  the  method. 
He  would  have  infinitely  preferred  a  smaller  number  of  well  observed  facts. 

See  also  a  talented  thesis  by  M.  Marc  d'Espine,  of  Geneva,  on  Comment 
un  Median  doit  il  Penser  ?  Comment  doit  il  -Agir  7  Paris,  1S33. — Cowan. 

X  Such  an  examination,  but  in  reference  to  diseases  of  the  brain  only,  was 
commenced  by  the  Paris  Society  for  Medical  Observation,  in  1834.  Every 
work  which  contains/acis  upon  the  subject  is  to  be  analysed.  —  H.  I.  B. 


xlviii 


TRANSLATOR  s   INTRODUCTION. 


Much  benefit  would  we  think  result  were  individuals  ap- 
pointed for  the  special  purpose  of  collecting  the  scattered  in- 
formation upon  different  subjects,  and  arranging  it  in  the  tab- 
ular form  ;  habit  would  render  the  method  less  laborious, 
and  point  out  some  improvements  in  the  process  :*  individual 
labors  would  thus  be  constantly  converging,  and  the  attention 
of  observers  be  particularly  directed  to  those  questions  which 
required  further  elucidation.  By  this  means,  many  investiga- 
tions which  every  conscientious  practitioner  is  compelled  to 
undertake  for  his  own  satisfaction  would  be  rendered  un- 
necessary ;  time  would  thus  be  saved,  and  exact  observations 
more  generally  collected,  not  only  because  the  labor  of  their 
analysis  might  be  entrusted  to  others,  but  the  advantages  of 
the  system  would  soon  be  so  apparent,  as  of  themselves  to 
become  sufficient  inducements.  The  bigoted  supporters  of 
hypothesis  would  cease  to  perplex  and  bewilder,  while  all  the 
intuitions  of  genius  would  find  materials  by  which  their  truth 
or  fallacy  might  be  determined  ;  we  should  at  length  leave 
those  first  principles  which  are  now  daily  questioned  and  con- 
tested, and  lay  the  foundation  of  future  progress  by  defining 
the  extent  of  the  knowledge  already  in  our  possession.  It  is 
only  (Herschel)  by  condensing,  simplifying,  and  arranging,  in 
the  most  lucid  possible  manner,  the  acquired  knowledge  of 
past  generations,  that  those  to  come  can  be  enabled  to  avail 
themselves  to  the  full  of  the  advanced  point  from  which  they 
will  start. 

The  author  in  his  preface  has  sufficiently  enlarged  upon 

*  Dr.  Todd's  book  of  analysis  contains  much  valuable  and  ingenious  in- 
formation, and  it  is  worthy  attention,  how  far  the  labor  may  be  reduced  by 
adopting  the  ideas  of  that  ingenious  writer.  We  recommend  the  work  to  the 
reader's  perusal.  —  Cowan. 


tbanslator's  introduction.  xlix 

the  plan  of  the  work  to  render  any  additional  remarks  un- 
necessary. As  translators  we  have  neither  altered  nor  abridged 
the  original,  and  have  been  as  literal  as  the  peculiarities  of 
either  language  would  admit.  The  nature  of  the  subject 
necessarily  excluded  great  choice  or  freedom  of  expression, 
and  the  frequent  repetition,  inevitable  in  the  arrangement  of 
such  numerous  details,  involves  a  monotony  of  style  which 
could  only  have  been  avoided,  by  increasing  the  size  of  the 
volume  and  more  or  less  deviating  from  the  rigorous  nature  of 
the  system  which  M.  Louis  has  followed.  For  the  same 
reason,  the  difficulties  of  translation  have  been  augmented, 
and  while  we  claim  the  benefit  of  this  consideration,  the 
reader  cannot  be  more  dissatisfied  with  the  manner  in  which 
our  task  has  been  performed  than  we  are  ourselves. 

By  omitting  many  of  the  observations  and  condensing  the 
results,  we  might,  perhaps,  have  rendered  the  work  more 
popular,  but  at  the  same  time  we  felt  that  this  could  not  be 
done  without  lessening  its  real  value.  The  pathology  of 
phthisis  has  not  as  hitherto  been  limited  to  the  description  of 
the  pulmonary  organs,  and  we  regard  the  results  arising  from 
the  examination  of  the  disease  in  a  general  "point  of  view,  and 
not  merely  as  a  local  affection,  as  amongst  the  leading  and 
most  valuable  features  of  the  work. 

The  remarks  following  the  individual  observations,  include 
much  valuable  information,  and  are  peculiarly  illustrative  of 
the  author's  reasoning  and  method  ;  by  either  omitting  or  cur- 
tailing them,  numerous  references  would  have  been  useless 
and  assertions  left  unsupported,  while  the  arrangement  of  the 
work  permits  the  study  of  the  principal  results,  independently 
of  the  facts  on  which  they  are  founded. 

After  the  accurate  researches  of  Bayle  and  Laennec,  M. 
7 


1  translator's  introduction. 

Louis  has  wisely  abstained  from  any  lengthened  and  minute 
details  on  the  pathology  of  the  lungs  ;  he  has  simply  described 
the  results  of  his  own  observation,  and  we  think  satisfactorily 
proved  the  dependence  existing  between  the  grey,  semi-trans- 
parent granulations  and  tubercles,  which  may  now  be  regarded 
as  occasional,  not  necessary  gradations  of  each  other.  He  has 
also  shown  how  easily  many  apparently  opposite  opinions  on 
this  much  contested  subject  may  be  reconciled,  when  all  the 
phenomena  attending  tubercular  deposition  are  fairly  appre- 
ciated. The  existence  of  tubercles  in  the  summit  of  the  lungs, 
their  gradual  progress  and  softening  from  above  downwards, 
the  presence  of  excavations  nearer  the  posterior  than  the  an- 
terior surface,  the  greater  frequency  of  tubercles  on  the 
left  than  the  right  side,  have  never  been  so  clearly  demon- 
strated. 

The  observations  on  the  state  of  the  bronchial  mucous 
membrane,  and  the  influence  of  the  contents  of  the  tubercular 
excavations,  are  peculiarly  interesting,  and  must  materially 
modify  our  ideas  as  to  the  agency  of  simple  bronchitis  in  the 
production  of  phthisis. 

The  pathology  of  the  larynx  has  never  before  been  minutely 
described,  and  we  think  the  author's  investigations  important, 
both  from  their  application  to  diagnosis,  and  from  their  giving 
clearer  ideas  of  what  is  really  included  by  the  term  "  laryn- 
gseal  phthisis." 

The  connexion  of  pneumonia  and  pleurisy  with  pulmonary 
tubercles,  the  state  of  the  pleurae,  the  situation  of  the  adhe- 
sions, their  influence  in  causing  thoracic  pains,  are  all  deserv- 
ing attention.  The  comparative  frequency  of  tubercles  in 
different  organs  of  the  body,*  and  especially  the  fact  that, 

*  We  would  refer  the  reader  to  some  highly  ingenious  and  interesting 
remarks  of  Dr.  Carswell  on  the  localization  of  tubercles  (Cyclop.  Pract. 


translator's  introduction.  It 

after  the  age  of  fifteen,  except  in  the  lungs,  they  are  generally 
every  where  at  the  same  stage  of  development,  form  impor- 
tant data  in  any  conjectures  we  may  make  as  to  the  nature  of 
the  disease.  They  are  powerful  arguments  in  favor  of  the 
affection  being  general,  and  not  depending  on  inflammation. 

The  pathology  of  the  digestive  tube  forms  perhaps  the  most 
valuable  part  of  the  volume,  and  is  calculated  to  modify  the 
usually  received  opinions  expressed  under  the  term  "  dyspeptic 
phthisis."  The  state  of  the  liver  contrasted  with  the  usually 
healthy  condition  of  the  spleen,  are  facts  of  considerable  in- 
terest, though  in  the  present  state  of  our  knowledge  they  can- 
not be  fully  estimated. 

The  comparative  examination  of  the  glandular  system  with 
the  mucous  membranes,  is  particularly  worthy  the  reader's 
attention,  as  it  directly  invalidates  one  of  the  most  popular 
pathological  doctrines  of  the  day. 

The  chapter  on  the  perforation  of  the  lungs,  contains  by  far 
the  most  exact  information  we  possess  on  this  important  com- 
plication, and  is  a  beautiful  illustration  of  the  necessity  and 
value  of  pathological  researches. 

The  description  of  the  symptoms,  their  succession,  duration, 
character,  variations,  and  relative  value,  merit  the  practition- 
er's serious  consideration,  and  should  be  studied  in  conjunction 
with  the  chapters  on  acute  and  latent  phthisis.  We  would 
particularly  point  out  the  observations  relative  to  the  cough, 
expectoration,  haemoptysis,  hectic,  diarrhœa,  and  emaciation. 

We  have  already  expressed  our  opinion  on  the  value  of  the 

Med.,  Vol.  xxii.  page  261),  tending  to  prove  that  there  are  other  causes 
besides  inflammation,  which  determine  the  presence  of  tubercnlous  matter 
in  particular  organs,  and  more  frequently  in  one  portion  of  an  organ  than 
another.  — Cowan. 


lii  translator's  introduction. 

chapter  on  diagnosis,  and  we  believe  made  some  useful  addi- 
tions, by  detailing  the  subsequent  experience  of  the  author. 

The  numerous  and  important  additions  we  have  appended 
to  the  chapter  on  the  "  causes'^  of  phthisis,  are  the  best  proofs 
of  our  individual  impression  as  to  its  importance.  Dr.  Clarke, 
in  the  preface  (page  20)  to  his  valuable  work  on  climate,  says, 
"  I  am  well  satisfied  that  it  is  only  by  a  knowledge  of  the 
causes  which  lead  to  it,  and  by  directing  our  efforts  to  coun- 
teract them,  that  ive  shall  ever  he  able  to  diminish  the  rav- 
ages of  consumption.^^ 

"The  tubercular  diathesis  (page  323),  is  also  induced  by 
the  operation  of  external  or  accidental  causes,  which  I  admit 
to  be  the  most  important  part  of  the  whole  inquiry  connected 
with  consumption."  "  Had  the  labor  and  research  that  have 
been  wasted  in  fruitless  experiments  to  cure  an  irremediable 
condition  of  the  lungs  been  directed  to  the  discovery  of  the 
causes  and  nature  of  tuberculous  disease,  with  the  view  of  de- 
ducing rules  for  its  prevention  and  treatment,  consumption 
would  be  regarded  in  a  light  very  different  from  that  in  which 
it  is  looked  upon  at  the  present  period."  Coinciding  with  the 
opinion  expressed  by  this  able  writer,  we  have  endeavored  to 
lay  before  the  reader  a  large  mass  of  circumstantial  detail,  which 
has  never  yet  been  approximated,  and  from  the  recent  nature 
of  a  great  proportion,  is  probably  unknown  to  the  majority  of 
our  readers.  It  cannot  fail,  we  think,  materially  to  modify 
many  of  our  most  generally  received  and  apparently  best 
established  opinions,  on  the  origin  and  nature  of  phthisis  ;  and 
if  in  some  of  our  deductions  we  have  differed  from  the  con- 
clusions attempted  to  be  drawn  by  the  authors  of  the  memoirs 
from  which  we  have  quoted,  with  respect  to  the  modus  ope- 
randi of  some  particular  influences,  that  difference  has  not 
arisen  from  any  depreciation  of  their  facts,   but  fronr  more 


translator's  introduction.  liii 

closely  associating  them  with  other  conclusions  deducible  from 
M.  Louis's  observations  as  to  the  nature  and  pathology  of  the 
disease. 

Much  misconception  has  hitherto  prevailed  on  this  most  im- 
portant subject,  and  for  its  satisfactory  elucidation  there  is  still 
great  need  of  minute  and  patient  investigation.  No  country 
possesses  more  means  for  the  determination  of  the  really  active 
causes  of  phthisis  than  England,  and  it  would  be  most  de- 
sirable that  government  would  enable  qualified  individuals  to 
devote  themselves  to  the  examination  of  those  influences, 
which  so  extensively  react  upon  the  general  health.  Accu- 
rate information  on  this  subject  would  materially  aid  the  pro- 
gress of  medicine  as  a  curative  art,  and  point  out  a  prophy- 
lactic treatment,  the  effect  of  which  on  the  prevalence  of 
national  disease,  and  more  particularly  of  consumption,  is 
incalculable. 

In  estimating  the  author's  remarks  on  treatment,  the  reader 
must  not  forget  the  nature  of  the  work  or  the  method  so  rigor- 
ously pursued.  Nothing  is  attempted  to  be  advanced  not 
strictly  included  in  the  facts  before  him,  and  M.  Louis  has 
purposely  abstained  ftom  referring  to  his  own  peculiar  views, 
either  in  pathology  or  therapeutics,  unless  directly  supported 
by  the  cases  he  is  analysing.  We  have  already  pointed  out 
that  the  number  of  the  observations  is  insufficient  to  arrive  at 
any  general  therapeutical  deduction,  and  the  conditions  of  a 
general  hospital,  combined  with  the  'advanced  stage  of  the 
disease  in  the  majority  of  instances,  render  the  trial  of  any 
peculiar  curative  measures  almost  impossible.  We  should 
regret  that  this  sterihty  of  treatment  should  form  any  argument 
against  the  advantages  of  pathological  research,  for  while  it 
cannot  be  denied  that  pathology  has  alreachj  greatly  rational- 
ized the  treatment  of  many  diseases,  let  it  be  remembered,  that 


liv  translator's  introduction. 

there  is  no  necessary  or  immediate  connexion  between  the 
knowledge  of  morbid  anatomy  and  curative  indications.  Dis- 
ease includes  far  more  than  the  physical  alterations  discovered 
after  death,  which  often,  indeed,  fail  to  explain  many  of  the 
functional  derangements  observed  during  life  ;  but  the  knowl- 
edge, which  in  the  majority  of  instances  is  in  our  power,  of 
what  organs  are  uniformly  or  secondarily  affected  under  cer- 
tain circumstances,  enables  us  more  clearly  to  define  the 
essential  pathological  characters  of  particular  affections,  and 
after  we  are  in  possession  of  this  knowledge,  to  apply  our 
remedies  under  the  most  favorable  conditions  by  which  their 
efficacy  may  be  determined.  Pathology  is,  therefore,  the 
predecessor  rather  than  the  contemporary  of  successful  thera- 
peutics ;  without  its  assistance  the  latter  has  no  other  hopes 
of  advancement  than  the  blind  chances  of  empyrical  experi- 
ment: the  value  of  these  chances  has,  perhaps,  in  the  minds 
of  some,  been  decided  by  the  experience  of  the  last  two  thou- 
sand years. 

But  while  thus  insisting  on  the  necessary  ultimate  influence 
of  pathology  on  treatment,  it  is  evident  that  we  cannot  defer 
the  application  of  remedies  until  our  knowledge  of  disease  is 
complete.  Treatment  must  be  tried,  whatever  obscurity  may 
exist  as  to  the  nature  of  the  affection.  The  absence  of  certain 
data  from  which  more  rational  indications  might  be  drawn,  must 
never  paralyze  the  exertion  of  our  talents  and  ingenuity  in 
the  discovery  and  apphcation  of  remedial  measures  ;  we  should 
always  endeavor,  as  far  as  facts  will  permit,  to  arrive  at  some 
probable  conclusions  ;  and  precisely  in  proportion  as  our  rem- 
edies have  failed,  we  are  justified  in  exceeding  the  bounds  of 
strict  logical  induction,  in  the  research  of  other  means  by 
which  disease  may  be  more  successfully  combated.  It  is  un- 
der this  impression  that  we  regret  the  author  has  not  deduced 


translator's  introduction.  Iv 

some  general  conclusions*  as  to  the  nature  and  treatment  of 
phthisis,  and  in  the  imperfect  attempt  we  have  made  to  sup- 
ply the  deficiency,  our  remarks  are  confined  to  a  few  infer- 
ential inductions  founded  on  a  review  of  its  pathology  and 
causes,  and  to  the  simple  exposition  of  those  means  which 
have  been  most  generally  vaunted  in  its  cure  ;  rather  wishing 
to  afford  materials  to  the  judgment  of  the  reader,  than  to 
bias  him  by  a  selection  of  what  would  simply  be  the  expres- 
sion of  our  own  individual  opinion. 

A  popular  and  too  often  professional  belief  that  phthisis  is 
incurable,  has  much  interfered  with  any  extensive  and  well 
combined  efforts  for  its  counteraction  ;  but  surely,  the  moment 
when  we  are  just  beginning  to  arrive  at  some  accurate  ideas 
as  to  its  causes,  its  nature,  and  its  seat,  is  ill  adapted  to  justify 
an  assumption  which  has  hitherto  been  but  the  avowal  of  our 
ignorance.  The  increased  information  we  possess,  loudly 
calls  for  fresh  opportunities  for  attempting  its  cure,  and  to  no 
object  could  national  or  individual  bounty  be  more  rationally 
or  usefully  devoted,  than  in  providing  means  by  which  the 
powers  of  medicine  might  be  advantageously  opposed,  to  what 
may  be  undoubtedly  considered  as  the  heaviest  penalty  which 
disease  exacts  from  civilized  man. 

When  we  reflect  that  from  one  fourth  to  one  sixth  of  our 
bills  of  mortality,  consist  of  the  victims  to  phthisis,  and  look 

*  It  seems  to  me  that  with  Louis's  strict  views  of  the  method  to  be  pur- 
sued in  the  study  of  diseases  and  of  their  treatment,  he  could  not,  without 
having  departed  from  these  views,  have  done  as  the  translator  regrets  he 
has  not  done.  He  gives  us  all  he  can  gain  from  a  strict  deduction  from  his 
facts,  and  leaves  to  others  to  try  other  modes  of  treatment,  and  see  if  they 
be  more  useful.  Had  he  made  any  "  general  conclusions  as  to  the  nature 
and  treatment  of  phthisis,"  he  would  have  fallen,  as  it  seems  to  me,  into 
the  same  error  which  most  writers  on  medicine  have  heretofore  fallen 
into,  viz.  that  of  substituting  speculation  ior proof.  —  H,  I.  B. 


Ivi 


TRANSLATOR  s    INTRODUCTION. 


round  on  the  numerous  institutions  this  country  can  boast  for 
a  variety  of  very  secondary  objects,  it  does  indeed  seem  pass- 
ing strange,  that  no  systematic  attempt  has  ever  been  made 
for  diminishing  the  ravages  of  consumption.  Our  Small  Pox, 
our  Lock,  our  Foundling  Hospitals,  are  far  less  imperatively 
needed  than  the  establishment  of  an  institution  specially 
adapted  for  the  cure  of  phthisis:  the  conditions  which  it 
ought  to  include  are  quite  incompatible  with  those  existing  in 
our  ordinary  hospitals,  and  we  do  not  hesitate  to  say,  that 
unless  the  general  influences  by  which  the  patient  is  sur- 
rounded are  regulated,  as  well  as  the  application  of  particular 
remedies,  no  rigorous  or  satisfactory  evidence  of  the  powers  of 
medicine  in  this  disease,  can  ever  be  obtained. 

We  have  no  intention  of  entering  into  any  details  on  this 
interesting  subject,  but  we  submit  the  propriety  of  establishing 
public  institutions  expressly  for  the  cure  of  consumption,  as 
strongly  deserving  the  attention  both  of  the  medical  profession 
and  of  the  country  at  large. 

In  our  remarks  on  treatment,  we  have  insisted  upon  the 
immense  importance  of  prophylactic  measures,  and  to  encour- 
age future  perseverance,  let  us  remember  that  we  are  still  in 
the  infancy  of  medicine,  still  standing  on  the  shore  with  the 
boundless  ocean  of  undiscovered  truth  in  our  view  ;  that  the 
infinite  capabilities  of  science  still  unfold  an  inexhaustible  field 
for  the  exercise  of  our  finite  comprehension,  we  ought,  there- 
fore, to  shrink  from  attaching  bounds  to  our  future  progress, 
recollecting  that  ignorance  is  the  only  known  limit  to  our  men- 
tal vision,  and  that  in  "  whatever  state  of  knowledge  we  may 
conceive  man  to  be  placed,  his  progress  towards  a  yet  higher 
state  need  never  fear  a  check,  but  must  continue  till  the  last 
existence  of  society."  Medicine  is  not  excluded  from  this 
encouraging  prospect,  and  we  cannot  help  anticipating  that 


translator's  introduction.  Ivii 

the  cure  and  the  comparative  extinction  of  phthisis  are  an^ong 
the  benefits  its  future  progress  will  confer  upon  mankind.* 

In  the  fourth  volume  of  the  Examen,  des  Doctrines  Médi- 
cales, by  M.  Broussais,  recently  published,  one  hundred  and 
thirty-five  pages  are  devoted  to  the  examination  of  the  present 
treatise  and  other  works  of  our  author.  The  unexpected 
length  of  the  preceding  remarks,  and  the  fact  that  M .  Louis 
has  himself  published  what  we  believe  will  be  considered  by 
every  impartial  mind  a  victorious  reply  to  the  illiberal  and 
prejudiced  criticisms  of  M.  Broussais,  forbids,  and  indeed  ren- 
ders unnecessary  at  the  present  moment  more  than  a  ïevf 
brief  observations.! 

The  most  fatal  inroads  upon  the  doctrine  of  irritation  have 
arisen  from  the  labors  of  those  whose  impartial  observation 
and  accuracy  of  description  give  them  the  highest  claims  to 
our  confidence.     The  two  fundamental  dogmas  of  the  system 

of  M.  B ,   viz.,  that  inflammation,   of  some  kind  or 

other,  is  the  active  cause  of  all  morbid  alterations,  and  that 
glandular  disease  is  consecutive  to  that  of  the  mucous  mem- 
branes, have  been  fatally  invalidated  by  their  comparison 
with  accurately  observed  facts. 

*  "  It  may  not  be  too  much  to  hope,"  says  Dr.  Carswell,  ''  that  by  means 
of  a  more  intimate  knowledge  of  organic  clieraistry,  we  may  yet  be  able  to 
detect  in  the  mucous  secretions  or  in  the  blood  those  changes  which  indi- 
cate the  existence  of  the  tubercular  diathesis,  and  thus,  perhaps,  be  led  to 
discover  a  remedy  for  the  disease  before  it  has  effected  its  localization,  and 
produced  changes  in  themselves  incurable."  The  same  pathologist  ob- 
serves, that  "  pathological  anatomy  has,  perhaps,  never  afforded  more  con- 
clusive evidence  in  proof  of  the  curability  of  a  di^ca-ie,  than  it  has  in  that  of 
tubercular  phthisis."  —  Cowan. 

t  Vide  Examen,  de  V Examen,  de  M.  Broussais,  relativement  à  la  Phthisic 
et  â  V  Affection  Typhoïde,  par  E.  Ch,  A.  Louis.     Paris,  1834.  —  Cowan. 


Iviii  translator's  introduction. 

The  first  we  have  always  regarded  as  one  of  those  proposi- 
tions most  easily  supported,  but  most  difficult  to  be  proved  ;  and 
it  is  only  by  an  indefinite  latitude  of  expression,  which  admits 
of  being  ingeniously  moulded  into  accordance  with  our  theo- 
retical wants,  that  so  much  has  been  written  in  the  defence  of 
an  idea,  which  too  often,  when  practically  applied,  has  no  other 
foundation  than  our  speculative  belief  in  its  existence.  By 
inflammation  we  must  either  include  a  certain  combination  of 
essential  conditions,  or  the  term  must  be  regarded  as  destitute 
of  all  scientific  importance  ;  to  employ  it  as  the  expression  of 
whatever  we  observe  contrary  to  what  results  from  a  state  of 
health  is  to  make  it  the  pliant  tool  of  assertion,  but  a  mere 
bugbear  in  scientific  investigation.  It  cannot  be  denied  that 
organic  and  constitutional  changes  are  constantly  occurring 
without  a  trace  of  those  phenomena,  usually  signified  by  the 
term  inflammation  ;  and  to  argue  on  the  presence  of  a  some- 
thing the  existence  of  which  could  never  have  been  suspected 
without  the  creative  powers  of  a  theory  is  to  reduce  facts  to 
the  bondage  of  opinion,  and  make  their  comparative  apti- 
tude for  the  support  of  our  own  preconceptions,  the  standard 
of  their  value. 

Much  benefit  has  resulted,  we  freely  admit,  from  the  re- 
searches of  M.  B ,  more  particularly  from  his  investiga- 
tions of  those  latent  forms  of  inflammation,  previously  so  im- 
perfectly known  and  irrationally  treated  ;  but  while  sensible 
of  his  merits,  and  charmed  with  the  genius  displayed  in  his 
writings,  it  is  impossible  not  to  trace  the  warpings  of  precon- 
ceived opinions,  and  feel  that  we  are  rather  persuaded  by  the 
talents  and  ingenious  hypothesis  of  the  writer,  than  the  cool 
impartial  deductions  of  philosophical  inquiry. 

The  dependence  of  glandular  disease  on  the  state  of  the 
mucous  membranes  is  still  more  tangibly  opposed  to  the  sim- 


translator's  introduction.  lix 

pie  evidence  of  observation  ;  and  we  think,  totally  irreconcil- 
able w^ith  the  varied  and  numerous  facts  adduced  in  the  course 
of  this  volume.  That  the  alterations  of  the  one  may  be  oc- 
casionally depending  on  and  consecutive  to  those  of  the  other, 
no  one  will  deny,  but  os  a  law  of  the  system,  it  cannot  be 
assented  to,  until  supported  by  more  satisfactory  proof  than 
the  genius  of  its  inventor. 

The  acrimonious  and  unfair  spirit  characterising  the  criti- 
cisms of  M.  B ,  cannot  but  be  regretted.  He  has  alter- 
nately impeached  the  accuracy  and  veracity  of  M.  Louis, 
while  he  acknowledges  him  as  "  de  lonne  foi,^^  when  his  con- 
clusions tend  in  the  least  to  coincide  with  his  own.  In  one 
page  he  speaks  of  the  work  as  deserving  to  be  read,  and  in  the 
next  styles  it  as  destitute  of  either  pathological,  therapeutic, 
or  physiological  merit  ;  in  short,  his  remarks  bear  the  stamp 
of  a  foiled  and  disappointed  theorist,  and  exhibit  the  workings 
of  a  powerful  mind  in  the  defence  of  a  system  it  had  toiled  to 
erect,  but  which  is  daily  tottering  under  the  relentless  battery 
of  facts. 

While  thus  depreciating  the  tone  of  prejudiced  and  illiberal 

feeling  which  pervades  the  strictures  of  M.  B ,  we  are 

not  anxious  about  their  effects  on  the  volume  before  us  ;  its 
merits  are  quite  independent  of  individual  opinion,  it  will  rise 
in  estimation  and  shed  increasing  lustre  on  its  author,  in  pro- 
portion as  hypothesis  becomes  subservient  to  the  evidence  of 
impartial  and  accurate  observation.* 

*  We  particularly  recommend  the  reply  of  M.  Louis  to  the  reader's  atten- 
tion, as  affording  a  striking  contrast,  in  its  cool  and  searching  reasoning,  to 
the  impetuous  and  contradictory  efTorts  of  wounded  self-love.  To  the  un- 
founded and  ahsurd  allegation  that  M.  L.  was  the  obsequious  follower  of 
Laennec,  he  replies,  "  What,  {Op.  Cit.  page  5.)  have  I  devoted  seven  years 
of  my  life  to  discover  in  observation  nothing  more  than  a  means  of  attacking 


Ix  translator's  introduction. 

the  opinions  of  M.  Broussais  ?  Indeed  I  was  actuated  by  a  higher  motive. 
M.  13 was  scarcely  thought  of,  and  I  cared  little  to  what  results  ob- 
servation would  one  day  conduct  me,  confident  that  when  I  did  methodical- 
ly investigate  the  facts  I  had  collected,  they  would  lead  me  to  true  I'esults, 
which  were  alone  important." 

In  reply  to  the  insinuations  of  M.  B against  his  probity,  he  remarks 

with  all  the  consciousness  of  innocence  and  the  force  of  truth,  "Let  the 
reader  judge,  if  one  who  for  nearly  seven  years  renounced  the  practice  of 
medicine  to  devote  himself  to  the  observation  of  facts,  let  him  say  whether 
this  individual  was  guided  by  the  desire  to  invent.'  Whether  these  seven 
years  of  study  ought  not  forever  to  have  sheltered  him  from  such  sus- 
picion .'  The  reader  may  regret  that  he  has  done  so  little  in  so  long  a  period, 
but  assuredly  he  will  not  impeach  his  integrity,  he  will  not  imagine  that  he 
has  been  actuated  by  other  than  conscientious  motives  .?"  —  Cowan. 

Translator. 
Bath,  Fee.  1835. 


AUTHOR'S    PREFACE. 


The  world  will  be  perhaps  surprised  at  fresh  researches 
upon  phthisis,  after  the  still  recent  labors  of  Bayle  and  of 
Laennec.  These  pathologists  have  indeed  so  accurately  de- 
scribed the  leading  symptoms  and  characteristic  lesion  of  this 
disease,  that  little  appears  left  for  their  successors  to  accom- 
plish, and  it  would  seem  useless  to  re-handle  a  subject  so 
skilfully  treated,  were  it  only  capable  of  being  studied  under 
the  same  point  of  view  j  but  the  plan  we  have  pursued  in  the 
present  work  is  different. 

Very  shortly  after  we  had  exclusively  devoted  ourselves  to 
observation,  we  ascertained  that  in  the  progress  of  phthisis,  as 
in  that  of  other  chronic  diseases,  the  greater  number  of  the 
functions  are  remarkably  disturbed  ;  that  the  organs  which  dis- 
charge them  are  more  or  less  profoundly  altered,  and  that  with 
regard  to  both  these  points  the  history  of  the  disease  was  very 
incomplete,  or  almost  wholly  neglected  ;  the  hope  of  supply- 
ing this  deficiency  was  the  source  of  our  present  undertaking. 
Numerous  facts  early  indicated  to  us,  that  the  history  of 
phthisis  could  be  elucidated  by  new  observations,  and  this 
conviction  was  an  additional  motive  for  persevering  in  those 
investigations,  of  which  the  volume  now  presented  to  the 
reader  is  the  result. 


Ixii 


AUTHOR  s    PREFACE. 


In  order  to  secure  the  greatest  possible  utility  to  our  labors,  we 
have  observed  phthisical  patients  with  the  same  care  we  should 
have  employed  in  collecting  the  history  of  those  attacked  by 
any  disease  but  little  known  ;  we  have  examined  the  state  of 
all  the  functions,  and  reverted  as  far  as  possible  to  their  respec- 
tive derangements,  previous  to  our  examination  of  the  patient  ; 
and  after  death  we  have  studied  all  the  viscera  with  equal 
attention.  This  method  was  tedious,  but  simple  and  certain  ; 
it  could  not  but  lead  to  exact  results,  and  this  impression  has 
rendered  light  the  fatigue  it  necessarily  included. 

Fully  convinced  of  the  importance  of  negative  facts,  and 
recollecting  the  embarrassment  and  regrets  of  Morgagni,  when, 
on  examining  the  observations  of  Walsalva,  he  found  no  men- 
tion of  certain  facts  of  this  description,  we  have  collected  them 
with  as  much  care  as  the  most  interesting  of  our  affirmative 
ones  ;  we  have  even  noted  down  indiscriminately  whatever 
the  patients  related  respecting  the  alteration  of  their  health  at 
any  period  of  their  lives,  provided  always,  that  the  circum- 
stances of  the  recital  gave  evidence  of  its  truth  :  we  left  to 
future  opportunities,  and  the  post  mortem  examination,  the 
task  of  pointing  out  the  facts  to  be  retained  or  suppressed.  It 
is  easy  to  form  a  just  idea  of  the  importance  of  negative  facts, 
if  we  reflect  that  organs,  when  their  structure  is  extensively 
modified,  frequently  give  rise  to  no  appreciable  symptoms,  and 
that,  if  this  absence  of  symptoms  has  not  been  expressly  speci- 
fied, we  cannot  form  a  proper  estimate  of  the  value  of  post 
mortem  appearances.  Hence  also  the  necessity  of  examining 
all  the  functions,  whether  apparently  disturbed  in  their  exer- 
cise or  not  :  —  another  method  may  suffice  for  the  verification 
of  what  observers  have  already  remarked,  but  it  can  conduct 
us  no  farther. 

To  remove  all  doubts  as  to  the  value  of  our  notes,  we  have 


author's  preface.  .  Ixiii 

always  mentioned  the  state  of  the  patient's  intellectual  powers  ; 
quite  decided,  when  we  had  to  investigate  facts  anterior  to  the 
period  of  our  own  observation,  only  to  rely  on  those  patients, 
whose  faculties,  and  more  especially  whose  memory  possessed 
a  certain  degree  of  development. 

We  have  paid  great  attention  to  our  mode  of  questioning 
invalids,  for  there  are  certain  questions  which  almost  inevitably 
dictate  the  answers.  As,  for  instance,  if  we  wished  to  discover 
whether  the  patient  experienced  pain,  or  any  uneasy  sensation 
on  either  side  of  the  chest,  we  mentioned  first  the  side  where 
we  supposed  the  pain  did  not  exist  ;  if  he  then  indicated  the 
other  side  as  the  seat  of  the  sufferings,  we  regarded  the  fact  as 
certain,  and  entered  it  as  such.  For  the  determination  of  old 
dates,  important  to  be  ascertained,  we  frequently  recurred  to  the 
subject,  asking  the  patient,  not,  if  he  had  experienced  such  a 
symptom  from  such  a  time,  but  how  long  he  had  experienced 
it.  It  is  evident;  that  to  the  first  question  a  patient,  annoyed 
or  weary,  might  answer  indijBferently  yes  or  no,  while  at  the 
second  he  is  compelled  to  reflect,  and  by  a  mere  hap-hazard 
reply  cannot  so  easily  lead  into  error. 

After  death,  we  have  described  with  all  the  precision  of 
which  we  are  capable,  the  situation,  the  form,  the  color,  the 
consistence,  and  the  thickness  of  organs  ;  in  a  word,  every 
alteration  of  tissue  which  they  might  present.  To  effect  this, 
we  have  never  examined  the  viscera,  with  the  exception  of  the 
brain,  in  their  natural  connexions  ;  for  in  this  situation  they 
are  generally  insufficiently  illuminated,  and  in  the  case  of 
organs  which  are  membranous,  thin,  and  compound  in  their 
structure,  as  the  stomach  and  intestines,  their  thickness  and 
consistence  cannot  be  properly  appreciated,  and  it  is  also  diffi- 
cult to  examine  the  whole  of  their  extent  ;  at  the  same  time 
many  alterations  such  as  small  superficial  ulcerations,  almost 


Ixiv  author's  preface. 

inevitably  escape  our  notice.  In  these  cases,  to  see  clearly,  we 
must  not  only  remove  the  parts,  but  free  them  by  repeated 
washings  from  the  various  substances  which  adhere  to  them, 
and,  as  was  almost  constantly  our  practice,  immerse  them  for 
an  hour  or  two  in  water. 

The  history  of  the  softening  of  the  brain,  is  of  itself  sufficient 
to  point  out  the  importance  of  examining  the  different  degrees 
of  consistence  of  our  organs.  It  is  well  known  that  the  brain 
may  be  softened  and  almost  liquefied,  without  any  very  sensi- 
ble change  of  color,  so  that  were  we  to  limit  the  examination 
of  this  viscus  to  this  single  circumstance,  our  deductions  would 
necessarily  be  of  no  importance.  The  same  remark  is  appli- 
cable to  mucous  membranes,  which,  although  retaining  their 
natural  paleness,  we  sometimes  find  as  soft  as  mucus. 

It  was  from  applying  these  principles  to  ourselves,  that  we 
thought  it  right  to  relinquish,  with  respect  to  certain  points,  the 
observations  we  collected  at  the  close  of  1821  and  the  com- 
mencement of  1822.  At  that  period  we  frequently  neglected 
to  remark  the  different  degrees  of  consistence  of  the  mucous 
membranes,  nor  had  we  directed  our  attention  to  certain  patho- 
logical states  of  the  stomach,  and  by  using  observations  thus 
incompletely  detailed,  we  should  certainly  have  fallen  into 
error,  and  announced  results  which  were  inexact.  Lastly, 
whenever  an  observation  appeared,  in  any  respect,  incomplete 
or  destitute  of  that  accuracy  which  we  believe  to  be  necessary, 
we  have  set  it  aside  ;  this  explains  why  our  sura-totals  are  not 
always  founded  on  the  same  number  of  facts. 

The  thickening  of  tissues  is  also  one  of  the  circumstances 
most  important  to  notice,  and  is  sometimes  the  only  appreciable 
organic  lesion  ;  as  in  certain  cases  of  hypertrophy  of  the  heart 
and  the  thickening  of  the  submucous  layer  of  the  large  intes- 
tine, which  we  shall  hereafter  describe. 


author's  preface.  Ixv 

Redness,  considered  by  itself,  offers  much  less  interest, 
although  many  among  the  most  enlightened  physicians  confine 
their  descriptions  of  membranous  organs  to  the  indications  of 
their  color.  Redness,  in  fact,  may  depend  upon  various 
causes,  either  upon  inflammation,  or  even  upon  the  effects  of 
simple  congestion  towards  the  close  of  life.  Of  this  last  asser- 
tion we  have  the  proof  in  certain  cases  of  sudden  death  occur- 
ring to  individuals,  who,  only  a  few  moments  before,  appeared 
in  perfect  health,  and  yet  whose  gastro-intestinal  mucous  mem- 
brane was  more  or  less  red,  but  at  the  same  time  neither 
thickened  or  softened  ;  while  in  the  majority  of  cases,  where 
the  symptoms  of  inflammation  of  this  membrane  have  been 
prominent,  there  are  redness,  thickening  and  softening.  It 
follows,  therefore,  that  redness  signifies  nothing,  unless  ac- 
companied with  some  alteration  in  the  consistence  and  thick- 
ness of  tissues,  and  where  no  such  change  is  discoverable,  it 
is  only  by  the  aid  of  the  symptoms,  that  the  cause  of  the  red- 
ness can  possibly  be  conjectured.  Let  us  add,  for  the  pur- 
pose of  better  illustrating  the  importance  of  the  alterations  we 
are  referring  to,  that  after  death,  redness  may  disappear, 
while  the  thickening  and  softening  of  our  tissues  are  un- 
affected.* 

The  observations  on  which  our  researches  are  founded 
were  collected  at  the  hospital  of  La  Charité,  commencing 
from  the  last  three  months  of  1821.  Since  that  period,  we 
have  noted  down  the  history  of  all  the  patients  admitted  into 
the  wards  of  M.  Chomel,  containing  forty-eight  beds,  equally 

*  This  remark,  when  extended  to  softening,  is  too  absolute.  There  can 
be  no  doubt  that  if  softening,  Uke  redness,  cannot  be  removed  after  death, 
it  may  under  certain  circumstances  be  either  produced  or  increased.  — 
Cowan. 

9 


Ixvi 


AUTHOR  s    PREFACE. 


distributed  between  men  and  women.  The  same  plan  has 
been'  pursued  in  the  description  of  every  case,  and  as  the  ex- 
actness necessary  for  such  a  task  did  not  appear  compatible 
with  the  practice  of  medicine,  the  latter  was,  for  a  time  at 
least,  relinquished.  We  have  since  regularly  passed  from 
three  to  four  and  sometimes  five  hours  a  day  at  the  hospital, 
devoting  at  least  two  hours  to  each  post  mortem  examination  ; 
and  although  habit  has  necessarily  familiarised  us  with  ana- 
tomical researches,  we  give  to  them  at  the  present  moment,  as 
much  time  as  we  did  two  years  ago  ;  fully  persuaded,  that  to 
observe  well,  we  must  not  observe  hastily;  that  the  only 
means  to  rectify  inevitable  errors  are  continually  to  re-examine, 
and  consequently  always  to  observe  an  object  however  familiar, 
as  if  presented  to  us  for  the  first  time. 

By  comparing  our  latest  observations  with  those  formerly 
collected,  we  have  been  enabled  to  convince  ourselves  of  the 
advantage  that  results,  at  least  when  there  is  any  intention  of 
publishing,  from  having  observed  at  an  age  when  we  can  esti- 
mate things  at  their  real  value  ;  when  experience  has  already 
warned  us  against  every  species  of  illusion  and  theory,  and 
when  the  first  mental  want  is  that  of  truth.  Study  was  not 
less  attractive  to  us  formerly  than  it  is  at  present,  but  a  theory 
presented  with  art  was  not  without  its  allurements  ;  precision 
was  less  studied,  and  we  devoted  less  time  to  the  determina- 
tion of  facts.  These  mental  tendencies,  so  contrary  to  sound 
observation,  were  at  once  depending  on  deficient  experience  and 
our  youth  ;  very  few  escape  their  influence,  and,  if  for  no  other 
reason,  we  ought  generally  to  place  less  reliance  on  the  labors 
of  young  observers,  and  especially  avoid  devolving  the  task  of 
observation  exclusively  upon  them.  Independently  of  the 
disadvantages  of  age,  it  may  also  be  said  with  truth,  that  we 
cannot  observe  for  others  with  the  same  zeal,  the  satrie  assi- 


author's  preface.  Ixvii 

duity,  the  same  precision,  that  we  should  employ  for  ourselves. 
Does  the  natural  philosopher  who  wishes  to  advance  the  pro- 
gress of  science  let  another  make  his  experiments?  Does  the 
chymist  confide  the  operation  of  analysis  to  one  just  entering 
upon  his  career  ?  And  if,  as  indeed  is  the  case,  there  is  a  com- 
plete analogy  between  the  physician  who  observes,  the  natural 
philosopher  who  experiments,  and  the  chymist  who  analyses, 
why  should  they  adopt  a  different  method  in  their  inquiries  ? 
It  is  not  enough  to  know  that  individual  observations  are 
necessary  in  medicine,  unless  we  are  at  the  same  time  con- 
vinced, that  to  render  them  valuable,  much  zeal,  much  time, 
and  much  practice  are  required.  Practice,  we  repeat,  for  to 
collect  observations  is  a  trade,  and,  like  all  other  trades,  must 
be  learned  and  cannot  be  divined. 

The  reader  will  pardon  us,  perhaps,  for  having  insisted  so 
much  on  the  care  we  have  bestowed  on  the  collection  of  our 
facts,  and  upon  the  distrust  with  which  part  of  those  daily 
published  ought  to  be  received,  if  he  reflects  that  the  edifice 
of  medicine  reposes  entirely  upon  facts,  and  that  truth  cannot 
be  elicited,  but  from  those  which  have  been  well  and  com- 
pletely observed.  Then,  and  then  only,  we  shall  be  enabled 
to  discover,  in  a  series  of  observations,  the  data  of  a  problem 
consisting  of  many  unknown  quantities  whose  value  we  are  to 
determine  ;  and  since  in  mathematics,  this  value  does  not  vary 
with  the  individuals  who  engage  in  the  solution  of  the  problem, 
we  ought  also  in  medicine  to  arrive  at  identical  results,  by  the 
analysis  of  the  same  observations  ;  always  admitting,  that 
where  a  mind  of  ordinary  power  arrives  at  few  general  deduc- 
tions, one  of  superior  capacity,  from  its  power  of  examining 
the  particular  facts  under  more  varied  aspects,  will  discover  a 
greater  number  ;  but  it  is  inevitable  that  exact  observations, 
studied  under  the  same  point  of  view,  must  conduct  every  one 


Ixviii  author's  preface. 

who  attentively  considers  them  to  identical  conclusions.  All 
is  no-t  then  obscure  or  uncertain  in  medicine,  when  the  obser- 
vations which  guide  us  are  exact  ;  but  what  results  can  be 
obtained  from  the  consideration  of  facts  which  are  doubtful, 
incomplete,  or  false  ? 

Besides,  the  means  we  employ  to  arrive  at  the  solution  of 
the  problem  are  in  no  degree  arbitrary  or  uncertain  ;  they 
consist  almost  wholly  in  bringing  together  the  symptoms  which 
reveal  the  disturbance  of  one  and  the  same  function,  and,  should 
death  occur,  in  comparing  those  symptoms  with  the  state  of 
the  organ  on  which  the  function  depended.  If  the  organ  be 
more  or  less  seriously  affected,  and  its  lesion  either  by  its  char- 
acter or  extent  explains  the  derangement  of  its  function,  and 
if  there  be  no  other  which  will  explain  it,  we  are  then  entitled 
to  regard  it  as  the  cause  of  the  symptoms  observed  ;  if,  on  the 
contrary,  the  function  has  been  deranged  while  the  organ  has 
not  undergone  any  perceptible  alteration,  we  must  then  refer 
the  disturbance  either  to  a  sympathetic  influence,  or  to  some 
constitutional  peculiarity.  Anorexia,  for  example,  is  one  of 
the  symptoms  of  gastritis,  yet  since  it  is  frequently  observed  in 
phthisical  patients  when  the  mucous  membrane  of  the  stomach 
offers  no  sensible  lesion,  we  are  forced  to  conclude  that  under 
these  circumstances  it  is  sympathetic,  or  depending  on  some 
general  influence,  as  for  instance  the  febrile  movement  ;  and 
that  a  function  may  therefore  be  deranged  for  a  considerable 
time,  while  no  alteration  of  structure  in  the  organ  on  which  it 
depends  can  be  observed. 

Nothing  is  more  simple,  but  at  the  same  time  nothing  is 
more  fatiguing  than  the  m.ethod  we  have  described  ;  for,  what 
numerous  tables,  what  separate  analysis  does  it  not  require  ?  It 
is  almost  entirely  to  this  purely  mechanical  labor,  that  we  have 
reduced  our  operations  on  the  facts  we  have  collected  ;  per- 


author's  preface.  Ixix 

suaded  that  the  most  faithful  analysis  of  the  greatest  possible 
number  of  exact  observations  upon  a  given  subject  constitutes 
the  greatest  value  of  a  work. 

Those  of  which  we  now  offer  the  result  are  in  number  one 
hundred  and  twenty-three.  Fifty  among  them  have  been 
scattered  through  the  course  of  the  work  as  witnesses  in  our 
favor;  and  since  we  believe  that  the  history  of  a  patient  is  not 
really  complete  unless  it  gives  at  least  a  succinct  idea  of  the 
condition  of  all  the  functions,  we  have  described  them  as 
briefly  as  possible,  with  the  state  of  suffering  or  otherwise  of 
the  different  organs.  This  has  appeared  to  us  the  more  in- 
dispensable, from  the  fact  that  nearly  all  our  observations  are 
examples  of  complications  more  or  less  numerous,  and  because 
it  is  necessary  to  form  a  correct  idea  of  their  mutual  influence. 
Had  we  confined  ourselves  to  a  single  class  of  symptoms,  we 
must  also,  in  the  description  of  organic  lesions,  have  been 
reduced  to  a  single  class  of  organs  ;  but  such  a  method  would 
have  deprived  our  observations  of  a  part  of  the  interest  they 
might  otherwise  present,  and  they  might  also  have  been  con- 
sidered as  negligently  collected.  We  may  add  that  our 
researches,  being  in  relation  to  a  considerable  number  of  topics, 
would  frequently  have  appeared  wanting  in  solidity,  had  the 
details  of  each  observation  been  limited  to  a  single  point. 

To  avoid  unnecessary  fatigue  to  the  reader,  we  have  arrang- 
ed all  our  cases  on  the  same  plan.  In  the  first  section  we 
described  the  state  of  the  functions  previous  to  the  entrance  of 
the  patient  into  the  hospital,  reckoning  from  the  day  when  he 
ceased  to  be  in  perfect  health.  In  the  next  division  we  men- 
tion what  remarkable  features  the  symptoms  presented  at  the 
moment  of  our  seeing  the  patient  for  the  first  time,  and  after- 
wards, in  as  many  separate  sections^  we  continue  the  history 


Ixx  author's  preface. 

of  each  function  until  death.  Lastly,  as  regards  the  anatomical 
lesions,  we  note  whatever  the  exterior  of  the  body,  the  head, 
the  neck,  the  chest  and  the  abdomen,  present  of  importance. 
In  this  manner  confusion  is  prevented,  each  object  has  a  sep- 
arate place,  and  if  at  any  time  we  wish  to  recur  to  the  symp- 
toms which  belong  to  any  particular  lesion,  it  is  only  necessary 
to  read  a  single  section. 

Impossible  as  it  is  to  give  all  the  observations  upon  which 
our  researches  are  based,  we  have  pursued  in  the  exposition 
of  our  facts  a  rather  different  method  from  what  we  should 
have  adopted  under  any  other  circumstances.  We  have 
divided  our  work  into  two  parts,  and  since  anatomy  is  the 
strongest  support  of  pathology,  we  have  commenced  the  anal- 
ysis of  our  facts  by  a  general  description  of  the  visceral  lesions. 
Those  of  the  lungs,  bronchia,  pleurae,  trachea,  larynx  and 
epiglottis  are  successively  described  ;  then  those  of  the  diges- 
tive apparatus,  he.  he.  ;  and  as  it  was  Important  not  only  to 
describe  all  the  morbid  alterations,  but  to  determine  if  those 
which  existed  elsewhere  than  in  the  lungs  were  peculiar  to 
phthisis,  we  have  investigated  the  condition  of  the  organs  in 
cases  fatal  from  various  other  chronic  diseases  whose  histories 
we  have  collected  ;  we  have  compared  facts  with  each  other, 
and  from  this  additional  labor  has  resulted  the  knowledge  of 
some  general  principles  not  perhaps  without  importance.  We 
have  also  mentioned  the  proportion  in  which  each  of  the  mor- 
bid changes  was  observed  ;  so  that  our  work  may  be  consider- 
ed, in  all  its  parts,  a  kind  of  statistics  of  phthisis. 

After  the  description  of  almost  every  organic  alteration,  we 
have  examined  the  causes  to  which  they  might  have  been 
attributed. 

Finally,  in  a  brief  summary  we  have  placed  before  the  view 


author's  preface.  Ixxi 

of  the  reader  the  general  result  of  all  the  facts  contained  in 
this  first  part. 

The  second  part  is  reserved  for  the  history  of  the  synaptoms. 
We  have  first  described  those  occurring  in  phthisis  when  free 
from  all  complication,  and  we  have  insisted  particularly  upon 
the  diagnosis  in  the  early  periods  of  the  disease  :  we  have  then 
detailed  the  symptoms  which  accompany  ulcerations  of  the 
epiglottis,  larynx  and  trachea  ;  those  which  belong  to  different 
lesions  of  the  mucous  membrane  of  the  stomach,  &;c.  he.  ;  the 
anomalies  which  phthisis  presents  in  its  acute  or  latent  form, 
and  the  accidents  resulting  from  the  perforation  of  the  pulmo- 
nary parenchyma  in  consequence  of  tubercular  softening,  form- 
ing a  communication  with  the  cavity  of  the  pleurae.  We 
have  also  related  several  cases  of  sudden  death,  and  endeav- 
ored by  the  comparison  of  facts,  to  estimate  the  value  of  some 
of  the  causes  to  which  the  development  of  pulmonary  tuber- 
cles is  attributed.  Finally,  we  have  very  briefly  pointed  out 
the  treatment  of  the  cases  whose  analysis  we  have  given. 

Our  first  intention  was  not  to  extend  our  researches  beyond 
the  bounds  of  a  memoir,  and,  consequently,  to  detail  a  very 
limited  number  of  individual  facts  ;  but  by  pursuing  this  plan, 
many  of  our  propositions  vpould  have  remained  whhout  proof, 
and  we  should  have  failed  in  the  performance  of  the  most 
essential  duty  which  devolves  upon  an  individual  who  writes 
upon  any  subject  whatever.  It  is  by  the  advice  of  M.  Chomel 
that  we  have  been  induced  to  extend  the  plan  of  our  researches  ; 
his  assistance  has  been  available  in  many  other  ways,  for  the 
compilation  of  the  present  volume,  and  we  feel  happy  in  giv- 
ing this  public  testimony  of  our  gratitude. 

Finally,  and  we  say  it  with  the  consciousness  of  deep  con- 
viction,   though  a  more   skilful  hand    would  perhaps  have 


Ixxii 


AUTHOR  s    PREFACE. 


thrown  greater  interest  over  the  long  series  of  lesions  and 
symptoms  we  have  described,  yet  it  could  not  have  employed 
greater  accuracy  or  impartiality.* 

*  This  work  was  presented  to  the  Royal  Academy  of  Medicine,  and  the 
report  made  in  relation  to  it  may  be  found  in  the  Revue  Médicale,!  Septem- 
ber, 1825. — Louis. 

i  The  reader  will  find  this  report  in  the  Appendix  by  the  American 
editor.  —  H.  I.  B. 


ANATOMICAL 


AND 


PATHOLOGICAL    RESEARCHES 


ON 


PHTHISIS 


FIRST    PART. 


PART    1. 

PATHOLOGICAL    ANATOMY. 

I.  In  this  first  part  we  shall  successively  describe  all  the 
lesions  observed  in  the  different  apparatuses  of  our  organs, 
and  subjoin  some  considerations  on  their  causes. 


CHAPTER  I. 

RESPIRATORY   ORGANS. 


ARTICLE     I. 

LUNGS. 

2.  Bayle  divided  phthisis  into  as  many  kinds  as  there  are 
organic  lesions  of  the  lungs  capable,  according  to  him,  of 
causing  death.  He  admitted  a  tuberculous,  a  granulated,  a 
cancerous,  a  melanotic,  a  calculous,  and  an  ulcerous  phthisis. 
M.  Laennec  thinks,  on  the  other  hand,  that  there  exists  but 
one  species,  the  tuberculous  phthisis,  that  is,  but  one  organic 
alteration  of  the  lungs  which  can  terminate  in  death  by  passing 
through  all  the  stages  of  inanition  (dépérissement),  and  with 
all  the  symptoms  which   belong  to   phthisis.     During  more 


4  PATHOLOGICAL    ANATOMY. LUNGS  ;  [Parti, 

than  three  years,*  that  we  have  carefully  collected  the  history 
of  all  the  patients  admitted  into  the  hospital  of  La  Charité,  in 
the  service  of  M.  Chornel,  v^^e  have  not  observed  a  single 
subject  who  died  of  phthisis  whose  lungs  did  not  present,  as 
the  principal  lesion,  a  greater  or  less  number  of  tuberculous 
excavations,  tubercles,  or  of  grey,  serai-transparent  granu- 
lations ;  so  that  our  own  observations  strengthen  those  of  M. 
Laennec,  and  with  us  as  with  him,  "  the  existence  of  tuber- 
cles in  the  lungs  is  the  cause,  and  constitutes  the  special  char- 
acter of  phthisis."! 

3.  Tubercles  are,  as  we  know,  tumors  of  a  dull  yellowish 

*  The  number  of  patients  adffiitted  into  the  wards  during  the  above-men- 
tioned period  was  1960,  of  which  358  died.  Out  of  these  last,  127  were  cases 
of  phthisis,  and  in  40  others  who  died  of  various  diseases,  tubercles  were  found 
in  the  lungs  ;  —  that  is,  in  nearly  one  half.  In  one  third  they  constituted 
the  principallesion.  Vide  Report  made  to  the  Royal  Academy  of  Medicine 
on  this  work  by  Chornel,  Royer  Collard  and  Bourdois. —  Revue  Médicale, 
Sept.  1S25.  —  Cowan.  —  Also,  Appendix  by  American  editor.  —  H.  I.  B. 

t  This  proposition  is  flatly  denied  by  M.  Broussais,  who  asserts  that  he 
has  frequently  seen  cases  of  consumption  from  chronic  inflammation  and 
suppuration  of  the  lungs,  where  no  trace  of  tubercles  existed  after  death. 
He  confidently  refers  to  ten  cases  detailed  ia  his  course  of  lectures  during 
the  winter  of  1833.  This  mode  of  reasoning  merely  says,  that  M.  Broussais 
includes  more  under  the  tei-m  phthisis  than  the  author  ;  though  many  of  the 
general  symptoms  of  phthisis  may  have  been,  and  no  doubt  were,  present  in 
the  cases  detailed  by  M.  Broussais,  we  do  not  hesitate  to  say  that  their  pro- 
gress would  have  distinctly  distinguished  them  from  those  attending  true 
phthisis.  —  Vide  Examen  des  Doctrines  Médicales,  par  F.  J.  V.  Broussais, 
3d  edition,  vol.  v.  page  330". 

The  following  assertion  of  P.  Desault,  of  Bourdeaux,  in  an  essay  on 
phthisis,  published  in  1733,  is  remarkable.  He  says  that  an  ulcer  of  the 
lungs  is  merely  an  effect  and  not  a  cause,  and  that  tubercles  constitute  the 
essence  of  consumption,  being  generally  nnteriov  to  hcemoptysis.  He  also 
notices  the  frequent  affection  of  the  liver.  —Cowan. 


Chap.   1.]      TUBERCLES  ;    MILTARÏ"    GRANULATIONS.  5 

white  aspect,  of  variable  consistence,  which  soften  after  a  cer- 
tain time,  empty  themselves  into  the  bronchial  tubes,  and  give 
rise  to  excavations  more  or  less  considerable. 

4.  Almost  invariably  they  were  more  numerous,  larger, 
more  advanced  in  their  development  at  the  summit,  than  at 
the  base  of  the  lungs  ;  for  in  the  one  hundred  and  twenty- 
three  cases  of  phthisis  we  are  going  to  analyse  we  have  met 
with  only  two  exceptions  to  this  rule  (Obs.  33.) 

2.  They  were  associated  with  a  production  of  a  very  differ- 
ent appearance,  we  mean  those  small,  homogeneous,  shining 
bodies,  of  marked  consistence,  more  or  less  rounded,  and 
varying  in  size  from  a  pea  to  that  of  a  millet-seed  ;  bodies 
which  have  been  designated  by  the  name  of  "  grey,  semi- 
transparent  granulations."  (Granulations  grises  demi-trans- 
parentes.)* 

These  granulations  form,  according  to  the  beautiful  re- 
searches of  Laennec,  the  first  stage  of  tubercles,  through 
which  the  latter  must  pass  before  assuming  those  characters 
which  are  peculiar  to  them.  As  in  the  case  of  tubercles,  we 
have  found  them  larger,  more  numerous  at  the  apex  than  at 
the  base  of  the  lungs,  and  limited  to  the  former,  if  not  existing 
in  the  whole  of  their  extent.  At  a  certain  period  of  their  de- 
velopment they  presented  a  yellow  opaque  pointât  the  centre  ; 
this  point  was  larger  in  proportion  as  the  granulations  were 
nearer  the  summit  of  the  lunchs,  and  in  examininçr  these  vis- 
cera  from  below  upwards,  the  lesions  were  generally  seen  in 
the  following  order  :  —  J  st,   grey,   semi-transparent  granula- 

*  Miliary  Granulations  of  Laennec.  Vide  Dr.  Forbes's  Translation, 
page  273.  We  adapt  our  references  to  this  work  instead  of  tlie  original,  as 
the  former  is,  perhaps,  more  generally  in  the  hands  of  the  English  reader, 
and  its  value  is  much  increased  by  Dr.  Forbes's  very  able  and  extensive 
additions.  —  Cov.'An. 


6  PATHOLOGICAL    ANATOMY.  LUNGS  ;  [Part  I, 

tions  ;  2dly,  granulations  less  clear  and  yellowish  towards  the 
centre,  and  3dly,  granulations  of  a  yellowish  white  in  their 
whole  extent  ;  that  is,  completely  tuberculous.  These  last 
were  in  the  majority  of  cases  the  only  ones  observed  at  the 
summit  of  the  lungs. 

6.  It  was  rare  to  find  either  tubercles  or  the  grey,  semi- 
transparent  granulations  existing  singly  in  the  lungs.  The 
first  of  these  cases  we  have  only  met  with  twice.  The  second 
we  have  observed  in  five  subjects,  though  even  here  there 
were  some  granulations  more  or  less  milky  and  yellowish  in 
the  centre. 

These  facts  appear  to  us  incontestably  to  establish  the  trans- 
formation of  the  grey,  semi-transparent  granulations  into  tuber- 
culous matter. 

7.  These  granulations,  usually  scattered,  in  many  cases 
formed  small  groups,  or  even  masses  of  an  irregular  figure,  and 
very  variable  dimensions. 

Most  frequently  they  existed  at  a  certain  distance  from  the 
pleura.  At  other  times  (in  about  one  third  of  the  cases)  they 
were  as  numerous  immediately  beneath  this  membrane  as  in 
the  more  central  parts  of  the  organ.  We  have  even  met  with 
an  instance  in  which  the  lung  remaining  free  from  all  adhe- 
sions, they  were  more  numerous  at  the  surface  than  any  where 
else  (Obs.  17.)  Thus  arranged,  they  gave  an  uneven  appear- 
ance to  the  lung.  Having  passed  into  the  tuberculous  state 
and  then  become  softened,  they  were  converted  into  abscesses, 
which  formed  elevations  more  or  less  considerable,  externally, 
occasionally  discharging  their  contents  into  the  cavity  of  the 
pleurae,  and  producing  the  accidents  we  shall  enlarge  upon  in 
our  chapter  on  the  perforation  of  the  lungs. 

8.  The  time  requisite  to  enable  the  granulations  to  acquire 
the  volume  of  a  small  pea  (the  size  most  frequently  observed), 


Chap.   1.]  SEMI-TRANSPARENT    MASSES.  7 

isj  no  doubt,  very  subject  to  variation,  and  almost  always  im- 
possible to  determine.  Yet,  some  cases  of  acute  phthisis 
seem  to  indicate  that  their  development  is  sometimes  very 
rapid,  and  that  they  can  acquire  the  volume  mentioned  in  so 
short  a  time  as  three  or  four  weeks  (Obs.  34).  On  the  other 
hand,  a  tolerably  numerous  series  of  observations  inclines  us 
to  the  opinion  that  they  may  remain  very  small  for  a  long 
period  after  their  formation.  Thus,  we  have  met  many  indi- 
viduals, who  coughed  continually,  had  been  subject  to  hae- 
moptysis for  many  years,  &;c.,  and  yet  who  presented  no  other 
lesion  of  the  pulmonary  parenchyma  than  the  grey  granula- 
tions, of  the  volume  already  indicated,  or  even  much  smaller. 

9.  This  grey,  semi-transparent  matter  presented  itself  also 
under  another  form  ;  it  was  frequently  in  irregular  masses, 
sometimes  of  considerable  volume,  from  about  one  to  two  or 
three  cubic  inches  (Obs.  29).  As  in  those  cases  where  it 
assumed  the  rounded  form,  it  was  shining,  homogeneous  and 
without  distinguishable  structure.  In  many  subjects,  in  the 
middle  of  these  masses,  a  variable  number  of  miliary  points  of 
a  dull,  yellowish  white,  in  every  respect  tuberculous,  could  be 
observed.  In  others,  the  transformation  was  almost  complete, 
and  some  small  portions  of  grey  substance  in  the  midst  of  a 
mass  of  tuberculous  matter  were  alone  discoverable. 

Thus,  whether  the  grey  matter  assumed  the  form  of  granu- 
lations or  of  irregular  masses,  more  or  less  considerable,  it  be- 
came sooner  or  later  transformed  into  tubercle. 

10.  We  have  met,  though  rarely,  the  grey  matter  in  other 
organs  ;  and  in  them,  as  in  the  lungs,  it  has  appeared  suscep- 
tible of  tubercular  transformation.  We  will  mention  in  support 
of  this,  the  case  of  the  seventh  observation,  where  we  found 
deposited  in  the  great  epiploon  and  mesocolon,  in  the  midst  of 
a  large  quantity  of  tuberculous  matter,   masses  more  or  less 


8  PATHOLOGICAL    ANATOMY. LUNGS  ;  [Parti, 

voluminous,  of  gi'ey,  semi-transparent  substance.  Is  it  not 
probable  that  this  last  would  eventually  have  undergone  the 
tuberculous  transformation  ?* 

1 1.  Laennec  has  observed  that  we  do  not  find  vessels,  or  at 
least  very  rarely,  in  the  masses  of  grey  matter.  We  have 
frequently  verified  the  truth  of  this  remark  by  the  aid  of  in- 
jections (Obs.  29). 

12.  Around  tuberculous  excavations,  which  were  rather 
large,  there  was  found  almost  constantly  a  certain  quantity  of 
this  same  grey  matter.  It  also  frequently  inclosed  on  all 
sides  some  semi-opaques  (louches)  and  yellowish  granulations, 
forming  them  into  a  compact  mass  more  or  less  considerable. 
In  this  way  we  have  seen  it  in  three  subjects  affect  a  very 
singular  arrangement,  and  present  itself  under  the  form  of 
zones.  These  were  three  in  number,  parallel,  situated  hori- 
zontally, occupying  the  whole  thickness  of  the  lungs,  they  were 
one  inch  in  height,  and  separated  from  each  other  by  a  layer  of 
pulmonary  tissue  of  similar  dimensions  (Obs.  46.) 

As  in  the  case  of  granulations,  the  grey  matter  in  form  of 
masses,  was  frequently  found  near  the  surface  of  the  lungs,  or 
immediately  under  the  pleurae  (Obs.  29,  35). 

13.  In  those  instances  where  the  progress  of  phthisis  was 

*  The  identity  of  the  grey,  semi-transparent  granulations  with  tubercle 
has  been  a  source  of  much  discussion.  Bayle  thought  them  cartilaginous, — 
Andral  (Clin.  Med.  vol.  ii.  page  5.),  indurated  pulmonary  vesicles,  —  Cho- 
mel  (Die.  de  Med.  vol.  x.  Article  "  Granulation")  says,  they[are  not  tuber- 
cles, but  vpithholds  his  reasons.  Bouillaud  seems  to  agree  with  andral. 
Lombard  entertains  a  very  similar  opinion,  &c.  We  only  mention  these 
hypotheses  to  attract  the  reader's  attention  to  the  evidence  adduced  by  our 
author  ;  it  is,  we  think,  conclusive,  and  coupled  with  other  facts  distributed 
throughout  this  volume,  demonstrate  some  necessary  i-elation  between  these 
two  alterations  as  strongly  as  it  is  in  the  power  of  facts  to  witness  in  favor  of 
two  things  which  are  not  absolutely  identical.  —  Cowan. 


Chap.  1.]  DEVELOPMENT    OF    TUBERCLES.  9 

rapid,  it  might  be  suspected  that  the  tuberculous  matter  had 
not  been  the  result  of  the  transformation  of  the  grey  matter, 
but  that  it  was  developed  primitively  under  the  form  of  tuber- 
cle, the  necessary  time  for  this  transformation  appearing  to 
have  been  wanting.  Such  would  be  considered  the  case  of  a 
young  girl,  who  forms  the  subject  of  the  thirty-fifth  observa- 
tion, where  we  found  a  large  mass  of  tuberculous  matter,  soft- 
ened, and  in  part  excavated,  on  the  thirty-fifth  day  of  the 
disease.  It  is  but  right,  however,  to  remark  that  in  the  case 
before  us  there  were  in  the  same  lung  both  tuberculous  and  grey 
matter;  and  in  many  other  cases,  where  the  progress  of  the  af- 
fection was  very  rapid,  (Obs.  36),  we  found  in  the  centre  of  one 
of  the  upper  lobes  a  certain  quantity  of  grey  matter,  almost  en- 
tirely transformed  into  softened  tubercle  ;  and  although  it  might 
have  developed  itself  consecutively  to  the  tuberculous  matter, 
a  contrary  supposition  is  not  less  probable  ;  so  that  doubts  as 
to  the  real  course  of  the  affection  in  these  different  instances 
must  necessarily  be  entertained.  It  is,  however,  on  the  whole, 
more  probable  that  tubercle  is  sometimes  developed  primitive- 
ly, as  such,  in  the  lungs;  for,  with  only  two  exceptions,  it  has 
always  appeared  to  us  to  affect  this  mode  of  production  in  the 
other  organs. 

14.  We  have  also  found  in  the  lungs  of  phthisical  patients, 
and  in  them  exclusively,  a  substance  less  firm,  more  trans- 
parent than  the  one  we  have  just  described,  of  a  dirty  red 
color,  or  sometimes  nearly  colorless,  presenting  more  or  less 
the  appearance  of  jelly  (Obs.  2).  This  substance,  which 
Laennec  has  described,  has  never  presented  tuberculous  par- 
ticles. Is  its  nature  identical  with  the  grey,  semi-transparent 
matter  ?* 

*"  Infiltration  Tuberculeuse  Gelât iniform e"  o(  Laennec.    Vide  Forbes' s 
Transi,  page  277.     M.  Louis's  observations  are   not  confirmative  of  Laen- 
B 


10  PATHOLOGICAL    ANATOMY.  LUNGS  ;  [Part  I, 

15.  Almost  invariably,  tubercles  existed  more  or  less  nu- 
merously in  both  lungs.  We  have,  however,  seen  this  lesion 
limited  five  times  to  the  left  lung,  and  twice  only  to  the  right. 
Can  we,  from  this  fact,  consider  the  right  lung  as  rather  less 
predisposed  to  the  development  of  tubercles  than  the  left  ? 

16.  We  have  remarked  that  tubercles  evinced  a  kind  of 
preference  for  the  summit  of  the  lungs  ;  that  here  they  were 
larger,  more  advanced,  and  comparatively  more  numerous. 
This  observation  is  still  more  applicable  to  the  upper  lobe, 
contrasted  with  the  lower,  than  to  the  lungs  in  general.  For, 
besides  the  large  excavations,  which  are  almost  exclusively 
found  in  the  top  of  the  upper  lobe,  grey  granulations,  tuber- 
cles, small  cavities,  he,  are  still  more  numerous  and  approxi- 
mated in  this  point  than  either  in  the  rest  of  its  extent,  or  in 
the  corresponding  portion  of  the  inferior  lobe.  We  have  also 
frequently  found  the  whole  of  the  upper  lobe  degenerated 
into  cavities,  and  into  the  grey  or  tuberculous  matter,  and 
throughout  wholly  impermeable  to  air,  whilst  at  the  same 
level  in  the  inferior  lobe  we  always  met  with  a  portion,  at 
least,  of  the  pulmonary  parenchyma,  capable  of  continuing 
respiration,  and  very  rarely  with  tuberculous  excavations. 
One  of  our  observations  of  acute  phthisis  is  an  example  of 
the  morbid  disposition  we  are  now  describing  (Obs.  36).  In 
thirty-eight  cases  (about  one  third  of  the  whole),  where  we 
have  encountered  it  in  nearly  a  similar  state,  it  existed  twenty- 
eight  times  in  the  left  side,  and  only  ten  times  in  the  right. 
An  additional  fact,  seeming  to  point  out  that  the  left  lung  is 
more  favorable  than  the  right  for  the  development  of  tuber- 

nec's,  who  says  he  has  frequently  seen  small  yellow  tuberculous  points  in 
this  substance,  which  he  regards  as  a  mere  variety  of  tuberculous  matter. — 
Cowan. 


Chap.   1.]  ORIGIN    OF    GREY    SUBSTANCE?  11 

des,  agreeing  with  what  we  have  mentioned  in  the  preceding 
paragraph.  The  history  of  the  perforation  of  the  substance 
of  the  Jung  (424)  is  no  less  in  consonance  with  this  con- 
ckision,  for  out  of  eight  cases  of  this  lesion  (the  only  ones  we 
have  collected)  seven  have  been  observed  as  belonging  to 
the  left  side.* 

However,  there  are  some  cases  (and  we  are  indebted  for 
the  remark  to  M.  Chomel)  where  a  part  of  the  grey  matter  of 
the  upper  lobe  appears  to  have  been  the  product  of  chronic 
inflammation.  Jt  had  not,  it  is  true,  that  granulated  aspect, 
which,  according  to  Laennec,  forms  the  anatomical  character 
of  the  second  or  third  degree  of  pneumonia  ;  but  it  presented 
a  general,  milky,  semi-opaque  appearance,  not  resulting  from 
miliary  granulations,  for  they  were  absent  ;  it  was  traversed  by 
white  dense  cellular  intersections,  as  distinct  as  those  we  see 
in  pneumonia  ;  it  was  more  compact  than  the  common  grey 
matter  ;  and  these  peculiarities,  when  well  marked,  appeared 
to  us  sufficient  to  distinguish  these  two  alterations  from  each 
other.  And,  with  respect  to  the  want  of  the  granulated  ap- 
pearance of  which  we  have  spoken,  there  is  nothing  absurd  in 
the  idea  that  it  may  be  the  effect  of  time,!   which  so  povver- 

*  This  opinion  is  contrary  to  that  of  Laennec,  but  in  unison  with  that  of 
Dr.  Stark  (Vide  Medical  Communications ,  page  35),  and  also  of  Dr.  Car- 
michael  Smith,  who  deduces  his  opinion  from  a  comparison  of  the  cases  in 
the  works  of  Bonetus,  Morg-ag;ni,  and  others.  (Vide  Forbes's  Transi,  page 
282,  note  by  Dr.  Forbes.)  The  fact  is  not  without  interest,  since  it  forms  a 
strong  argument  against  the  inflammatory  origin  of  tubercles,  as  the  reader 
will  see,  in  the  section  "On  the  Influence  of  Pneumonia  on  Phthisis."  — 
Cowan. 

t  This  is  the  opinion  of  the  youni',er  M.  Andral.  M.  Andral  thinks  likewise 
that  pneumonia  has  its  seat  in  the  minute  air  vessels  of  the  lungs,  and  from 
this  we  should  obtain  a  very  simple  explanation  of  the  granulated  aspect  of 
the  lungs  in  this  disease.     This  ingenious  idea  seems  to  us  to  be  more  than  a 


12  PATHOLOGICAL    ANATOMY.  LUNGS  ;  [Parti, 

fully  modifies  and  changes  the  characters  of  all  pathological 
alterations. 

17.  We  have  only  once  met  with  encysted  tubercles.* 
They  were  situated  at  the  summit  of  the  lungs,  and  easily 
separable  from  the  surrounding  tissues  (Obs.  31 .) 

18.  The  softening  of  tubercles  took  place  at  very  different 
periods  :  in  some  cases  from  the  twentieth  to  the  fortieth  day, 
counting  from  the  commencement  of  the  disease  (Obs.  33)  ; 
in  general,  at  a  much  later  period.  It  presented  the  same 
features  as  the  transformation  of  the  grey  into  tuberculous 
matter,  beginning  in  the  centre  of  the  tumor,  and  proceeding 
from  the  summit  to  the  base  of  the  lungs  ;  and  by  examining 

mere  hypothesis.  For  when  we  fill  the  bronchia  with  injection,  and  the 
injected  matter  has  been  forced  in  softly,  we  iind  in  the  lungs  an  infinite 
number  of  small  masses,  which,  on  being  divided,  present  exactly  the  gran- 
ulated appearance  of  which  we  are  speaking,  but  if  the  injection  has  been 
made  with  more  violence,  the  lungs  then  present  merely  a  compact  mass,  in 
which  the  granulated  aspect  has  almost  entirely  disappeared.  Does  not  this 
two-fold  experiment  seem  to  demonstrate  at  the  same  time  the  granulated 
aspect  of  the  lungs  in  acute  pneumonia,  and  its  disappearance  when  the  dis- 
ease is  in  a  chronic  state  ?  —  Louis. 

*  Laennec  considers  them  very  rare  ;  Bayle  has  described  them,  page  21. 
The  remark  is,  however,  principally  interesting  as  an  argument  for  the 
organization  of  tubercles.  All  secretions  not  organizable  must  be  expelled 
or  encysted  ;  therefore,  every  secretion  which  does  not  tend  to  encyst  itself ^ 
and  which  can  exist  a  long  time  without  producing  irritation,  shares  in  the 
common  life.  Is  not  this  very  often  the  case  with  tubercles  ?  When  tuber- 
culous matter  is  rapidly  deposited,  it  then  acts  as  a  foreign  body,  and  the  ac- 
cession of  general  symptoms  immediately  follows,  as  we  see  in  acute  phthisis. 
Organized  morbid  productions,  after  a  time,  secrete  non- assimilable  pro- 
ducts, which  become  the  cause  of  their  destruction.  The  softening  of  can- 
cer is  noûnng  more  than  thisj  that  of  tubercles  is  sometimes  analogous. 
We  refer  our  readers  to  an  ingenious  paper  on  this  subject  by  Trousseau 
and  Leblanc.  —  archives  Générales  de  Médecine,  1828.  —  Cowan. 


Chap.  1.]      cavities;  their  parietes,  he.  13 

them  in  this  direction,  we  successively  found,  at  various 
heights,  excavations,  softened  tubercles,  crude  tubercles,  and 
the  grey,  semi-transparent  granulations. 

Instead  of  taking  place  in  a  gradual  manner,  the  softening 
sometimes  occurred  simultaneously  over  a  considerable  extent 
of  surface,  and  the  whole  of  one  lobe  degenerated  into  tuber- 
culous matter,  was  nearly  equally  soft,  and  easily  broken  down 
throughout  the  whole  of  its  extent.  These  were  rare  cases, 
and  confined  exclusively  to  acute  phthisis  (Obs.  36).  There 
was  even  here  an  incomplete  cavity  at  the  top  of  the  upper 
lobe,  of  which  the  remainder  was  tuberculous  and  almost 
equally  softened. 

19.  We   have  not  found  tuberculous  excavations  entirely 
empty  before  the  end  of  the  third,  or  the  commencement  of 
the  fourth  month,  counting  from  the  invasion  of  the  disease. 
At  this  period,  the  parietes  of  the  cavities  were  generally  soft, 
and  lined  by  a  false  membrane  of  little  consistence  and  easily 
separated.     The  pulmonary  tissue  itself  was  very  rarely  ex- 
posed.    When  the  disease  had  a  more  distant  origin,  and  the 
cavities  were  more  ancient,  (which  could  be  substantiated  by 
the  exact  history  of  the  symptoms,  and  the  comparative  results 
of  auscultation),  their  sides  were  almost  constantly  more  or 
less  resisting,  formed  of  tuberculous  matter,  of  the  grey,  semi- 
transparent  substance,  and   sometimes   of  melanosis.     These 
different  alterations,   either  separated  by  a  small  quantity  of 
healthy  pulmonary  tissue,  or  continuous  with  each  other,  were 
variously  combined.     The  membrane   which  lined  the  exca- 
vation  was   dense,    greyish,    almost  semi-transparent,   semi- 
cartilaginous,  from  one  third  to  one  fourth  of  a  line  in  thick- 
ness,  sometimes   less,   and    generally    covered    by   another 
membrane  of  very  slight  consistence,  of  a  yellowish  or  whitish 
color,  and  usually  distributed  in  patches.     In  one  fourth  part 


14  PATHOLOGICAL    ANATOMY.  LUNGS  ;  [Part  I, 

of  the  cases  we  have  found  no  membrane  at  all,  and  when 
this  was  the  fact,  the  pulmonary  tissue^  more  or  less  consider- 
ably modified,  was  uncovered. 

20.  Large  or  small,  old  or  recent,  the  excavations  commu- 
nicated with  the  bronchia  by  a  greater  or  less  number  of  open- 
ings. The  mucous  membrane  of  the  latter,  and  the  false 
membrane  of  the  former,  were  closely  connected  at  the  en- 
trance of  the  excavation  ;  and  when  the  parietes  of  the  bronchia 
were  red,  their  limits  could  only  be  determined  by  means  of 
dissection. 

21.  Old  excavations  still  further  differed  from  those  which 
were  recent  in  their  being  uneven,  rugged,  and  generally  com- 
municating with  smaller  cavities.  They  were  frequently 
crossed  in  different  directions  by  cord-like  intersections. 
These  were  variable  in  length,  uneven,  narrow,  from  one  to 
two  lines  in  thickness,  formed  by  the  grey,  semi-transparent 
matter,  interspersed  with  tubercles,  and  thinner  in  their  middle 
portion  than  at  their  extremities  :  it  was  very  rarely  that  vas- 
cular ramifications  could  be  detected  in  them.  We  have, 
however,  seen  them  in  five  cases,  either  with  or  without  the 
aid  of  injection  (Obs.  31). 

22.  The  presence  of  vascular  ramifications  in  the  centre  of 
these  cord-like  prolongations  proves  the  destruction  of  a  cer- 
tain portion  of  surrounding  tissue  ;  and  this  fact  is  suflîcient  to 
point  out,  that  in  all  cases  of  large  excavations,  some  destruc- 
tion of  the  pulmonary  parenchyma  must  previously  take  place. 
The  rupture  of  bronchial  vessels  in  the  neighborhood  of  these 
excavations,  their  obliteration  in  the  parietes,  their  direction, 
which  often  indicated  their  passage  across  the  space  they  oc- 
cupied, may  be  mentioned  as  additional  proofs. 

It  may  happen,  also,  as  Laennec  has  said,  that  granulations 
are  developed  in  the  interstices  of  the  pulmonary  parenchyma  ; 


Chap.  1.]      CAVITIES  ;  form,  situation,  &;c.  15 

but  when  they  are  sufficiently  contiguous  to  excite  around 
them  the  development  of  the  grey,  semi-transparent  matter 
which  unites  them,  a  destruction  of  the  parenchyma  is  here 
equally  a  necessary  consequence.  The  tissues  comprised 
between  the  granulations  have  disappeared  ;  so  that  excava- 
tions of  very  moderate  dimensions  suppose,  as  in  the  case  of 
the  larger,  the  destruction  of  some  portion  of  the  substance  of 
the  lungs. 

23.  The  great  tuberculous  excavations  of  the  upper  lobe 
were  nearer  the  posterior  than  the  anterior  edge  of  the  lung,* 
and  in  many  instances  we  have  found  their  sides  in  the  former 
direction,  almost  wholly  formed  by  a  false,  semi-cartilaginous 
membrane,  from  a  line  to  a  line  and  a  half  in  thickness,  en- 
veloping the  summit  of  the  organ.  Inferiorly,  they  were 
sometimes  only  separated  from  the  pleura  which  covers  the 
interlobular  fissure  by  a  thin  layer  of  pulmonary  tissue,  more 
or  less  modified  (Obs.  28),  or  there  was  a  perforation  of  their 
parietes  in  this  point,  and  communication  established  between 
another  excavation,  situated  in  the  inferior  lobe  and  posteriorly  ; 
for  it  is  worthy  of  remark,  that  in  no  one  instance  have  we 
met  extensive  excavations  in  the  centre  of  the  lower  lobe. 
The  following  observation  is  a  very  remarkable  example,  both 
of  the  facts  we  have  last  described,  and  an  illustration  of  the 
great  size  tuberculous  excavations  may  attain. 

*  This  opinion  coincides  with  Dr.  Stark,  (Medical  Communications,  page 
369),  and  with  Dr.  Young,  page  32.  — Cowan. 


16         PATHOLOGICAL  ANATOMY. LUNGS  ;    [Part  I, 


FIRST    OBSERVATION. 

A  GIRL,  set.  20,  of  rather  delicate  constitution,  but  generally 
free  from  sickness,  was  admitted  into  the  hospital  of  La  Charité, 
August  24th,  1824.  She  had  not  ceased  growing,  and  had 
been  confined  without  accident  more  than  eight  months  pre- 
viously. With  the  exception  of  some  pains  in  the  epigastric 
region,  which  were  complained  of  during  her  pregnancy,  she 
enjoyed  good  health  during  the  first  two  months  following  her 
confinement,  after  which  period  she  experienced  all  the  symp- 
toms of  phthisis.  The  cough  and  expectoration  had  com- 
menced together,  and  had  been  more  urgent  the  last  two 
months.  To  this  increase  of  the  two  principal  symptoms  was 
added  considerable  oppression,  with  pains  between  the  shoul- 
ders and  at  the  middle  of  the  sternum.  There  had  been  only 
very  slight  haemoptysis.  The  voice  had  been  weak  the  last, 
fifteen  days,  and  had  finally  become  extinct  ;  appetite,  varia- 
ble from  the  commencement  ;  frequent  nausea,  and  a  more  or 
less  painful  state  of  abdomen  ;  for  the  last  twenty-four  hours 
the  patient  had  vomited  without  apparent  cause.  The  diar- 
rhœa  had  been  constant  for  the  last  four  months  ;  heat,  much 
augmented;  copious  sweats  during  the  night,  and  gradual  loss 
of  flesh.  Rigors  had  been  present  from  the  first,  and  had 
continued  almost  every  day  since. 

On  the  25th  of  April  the  face  was  pale  and  had  an  ex- 
pression of  fatigue  ;  slight  headache  ;  sleep,  continues  inter- 
rupted, as  during  the  last  three  months  ;  intelligence,  unaffect- 
ed. Cough,  moderately  frequent  ;  sputa,  of  a  greenish  color, 
imperfectly  nummulated  (pelotonnés),  in  small  quantity  and 
of  a  nauseous  odor,  as  was  also  the  patient's  breath  ;   voice, 


Chap.  1.]  SIZE  or  cavities.  17 

feeble,  and  slightly  changed  in  character;  percussion,  clear 
under  both  clavicles  ;  sense  of  heat,  pectoriloquy  and  metallic 
tinkling  during  the  cough  on  inspiration  and  expiration,  heard 
under  the  right  clavicle.  Tongue,  natural  ;  incomplete  ano- 
rexia, with  sense  of  weight  in  epigastric  region  immediately  after 
eating  J  habitual  pain  in  the  same  region;  hypogastrium,  sen- 
sible to  pressure  ;  the  previous  evening,  three  stools  with  colic 
pains.  Pulse,  small  and  weak,  extremely  rapid  ;  heat  slightly 
elevated  ;  night  perspirations.  Great  weakness  and  extreme 
marasmus.  The  patient  had  come  to  the  hospital  under  a 
feeling  of  despair,  and  expressed  much  anxiety  to  be  cured. 
Decubitus  on  the  left  side. 

On  the  17th,  she  complained  of  a  rather  acute  pain  in 
right  side  of  chest,  and  on  the  18th,  at  three,  p.  m.,  expired, 
almost  without  a  struggle,  retaining  her  consciousness  to  the 
last. 

Opening  of  the  corpse  forty  hours  after  death. 

Exterior.  —  Extreme  emaciation.  Nothing  else  remark- 
able. 

Head.  —  Two  small  spoonfuls  of  serosity  in  upper  portion 
of  the  arachnoid;  pia  mater,  slightly  red  colored;  brain, 
healthy  ;  half  a  spoonful  of  clear  fluid  in  each  lateral  ventricle. 

Neck.  —  Epiglottis,  larynx  and  trachea,  natural. 

Thorax.  —  The  right  lung  adhered  pretty  strongly  by  its 
summit  and  posteriorly  over  the  greater  part  of  its  extent  to 
the  pleura  costalis,  by  means  of  a  strong  and  moderately  thick 
false  membrane.  Its  external  surface  instead  of  being  convex, 
as  in  the  natural  state,  presented  a  large  and  deep  hollow 
formed  by  an  excavation,  which  we  judged  to  occupy  three 
fourths  or  four  fifths  of  the  total  volume  of  the  lungs.  It 
c 


18  PATHOLOGICAL  ANATOMY.  LUNGS  :    [Pai't  I, 

reached  from  the  summit  to  within  three  quarters  of  an  inch  of 
llie  base  of  the  organ,  and  from  the  posterior  part  to  within  half 
an  inch,  or  nearly  so,  of  the  anterior.  It  contained  a  moderate- 
ly thick,  turbid  substance,  of  greyish  and  brownish  color,  with 
an  odor  analogous  to  that  of  animal  matter  after  having  been 
some  time  macerated.  Its  parietes  were  extremely  uneven  ; 
presenting  in  many  places  fragments  of  pulmonary  tissue 
greatly  changed,  and  on  the  point  of  being  detached;  no  false 
membranes  were  observed  ;  the  external  boundary  was  from 
one  to  three  lines  in  thickness,  and  sometimes  much  less.  At 
the  part  corresponding  to  the  interlobular  fissure,  the  cavity 
was  divided  unequally  by  means  of  a  septum,  pierced  with 
numerous  large  openings,  and  formed,  as  the  rest  of  the  cir- 
cumference, by  a  grey  and  sometimes  bluish  and  semi-transpa- 
rent matter  studded  with  tubercles.  The  right  bronchial  tube 
opened  into  this  enormous  cavity,  about  half  an  inch  after  its 
entrance  into  the  lung,  and  was  much  more  dilated  than  that 
of  the  opposite  side.  The  remainder  of  the  lung  contained 
numerous  grey  and  tuberculous  granulations,  leaving  scarcely  a 
tenth  of  its  volume  capable  of  respiration.  The  upper  part  of 
the  left  lung  adhered  slightly  to  the  costal  pleura,  and  present- 
ed a  small  cavity  capable  of  containing  a  walnut,  surrounded 
with  grey,  semi-transparent  matter,  but  with  a  still  larger  pro- 
portion of  tubercles.  A  great  number  of  grey,  semi-trans- 
parent granulations  existed  in  the  lower  part  of  this  lobe,  con- 
gregated in  small  masses,  many  being  very  superficial,  and 
giving  a  nodulated  appearance  to  the  lung  externally.  Very 
few  were  found  in  the  lower  lobe.  Heart,  sound  ;  aorta,  red 
in  the  whole  of  its  course,  and  this  redness  extended,  while 
diminishing  in  intensity,  into  the  carotid  and  femoral  arteries. 
No  sensible  alteration  in  the  thickness  and  consistence  of  the 
arterial  coats. 


Chap.    1.]  SIZE    OF    CAVITIES.  19 

Abdomen.  —  Liver,  voluminous,  of  a  dull  yellow  color, 
overlapping  part  of  the  stomach  ;  moderately  firm,  and  some- 
what fatty.  The  bile  was  thick  and  tenacious.  The  stom- 
ach presented  a  bluish  tint  externally  in  the  part  corresponding 
to  the  great  cul-de-sac.  Volume,  natural.  Although  de- 
tached with  the  greatest  possible  care  from  the  spleen  and 
adjacent  organs,  there  was  a  perforation  of  nearly  an  inch  in  di- 
ameter, to  the  left  of  and  posteriorly  to  the  cardiac  orifice,  with 
extremely  thin  and  discolored  edges,  formed  of  the  peritoneum 
and  a  very  thin  layer  of  submucous  tissue.  Internally  the  prin- 
cipal part  of  the  great  cul-de-sac  and  of  the  anterior  parietes 
was  of  a  pale  bluish  color,  with  the  veins  strongly  defined. 
The  mucous  membrane  of  the  same  portions  was  reduced  to 
the  consistence  of  mucus,  and  not  thicker  than  common  blot- 
ling  paper.  It  was  similarly  affected,  in  bands  of  from  three 
to  four  lines  wide  throughout  the  remainder  of  its  extent  ;  and 
in  the  intermediate  spaces  was  of  a  tolerably  bright  red  color 
and  moderate  consistence.  Mucous  membrane  of  the  small  in- 
testines, perfectly  sound,  with  the  exception  often  very  small 
ulcerations  in  the  neighborhood  of  the  caecum.  Between  the 
mucous  and  the  submucous  tissues,  were  some  small  whitish 
indurations,  rather  larger  than  millet-seeds,  but  not  of  decidedly 
tuberculous  character.  In  the  large  intestine  the  mucous 
membrane  was  pale,  free  from  ulceration,  slightly  thickened 
and  soft  as  mucus.  The  mesenteric  glands  were  sound  ; 
spleen,  rather  softer  than  natural  ;  uterus,  extremely  small,  not 
more  than  fifteen  lines  in  its  transverse  diameter.  No  other 
appreciable  alteration  of  the  various  organs. 

24.  The  clearness  of  percussion  below  the  right  clavicle, 
combined  with  the  pectoriloquy  and  the  metallic  tinkling  in 
the  same  region,  proved   to  demonstration  the  existence  of  a 


20  PATHOLOGICAL    ANATOMY.  LUNGS  ;  [Part  1, 

vast  excavation  containing  both  air  and  liquid  (285).  We 
were,  however,  far  from  thinking  it  so  considerable.  No 
doubt,  if  the  weakness  of  the  patient  had  not  prevented  the 
examination  of  the  respiratory  phenomena  posteriorly,  we 
should  have  acquired  new  data  for  the  more  exact  appre- 
ciation of  the  size  of  the  excavation  ;  but  even  then  it  is 
more  than  probable  that  we  should  not  have  entirely  avoided 
error,  and  that  we  should  have  ascribed  to  a  large  number  of 
cavities  communicating  with  each  other,  the  effects  which  here 
depended  on  one  alone.  The  imperfect  septum  existing  in 
the  upper  part  of  the  excavation  was  formed  by  the  adhesion 
of  the  corresponding  portion  of  the  upper,  middle  and  lower 
lobes  reduced  at  this  point  to  a  very  inconsiderable  thickness. 
The  odor  of  the  contained  fluid,  identical  with  that  of  the  ex- 
pectoration, and  the  half  putrefied  portions  of  lung  still  attach- 
ed to  the  sides  of  the  cavity  are  not  less  remarkable  than  its 
unusual  dimensions.  This  may  also  be  said  of  the  dilated  and 
short  bronchial  tube  which  opened  into  it  ;  and  we  can  easily 
conceive  how,  in  similar  circumstances,  portions  of  the  lung 
itself  may  be  expectorated.  In  fact,  from  some  particulars 
mentioned  by  the  patient's  mother,  it  would  appear  that  some 
fragments  of  the  pulmonary  tissue  had  been  noticed  in  the 
expectoration  a  few  days  previous  to  her  admission  into  the 
hospital.  But  patients  and  their  attendants,  observe  with  too 
much  prejudice  to  allow  their  simple  testimony  to  have  much 
weight  in  the  determination  of  a  fact  of  this  description. 

Let  us  also  remark,  that  notwithstanding  the  great  extent  of 
the  disorder,  there  had  only  been  a  very  slight  haemoptysis  ; 
that  the  progress  of  the  affection  was  rapid  ;  and  finally,  that 
this  observation  is  an  instance  of  the  disproportion  so  frequent- 
ly existing  in  phthisical  patients  in  the  relative  state  of  the 
two  lungs. 


Chap.   1.]  CONTENTS    OF    THE    CAVITIES.  21 

25.  In  fact,  although  in  the  great  majority  of  cases  tuher- 
culous  excavations  are  found  in  both  lungs,  this  is  not  constant. 
In  the  sixth  part  of  our  observations  they  only  existed  in  one 
side  or  the  other,  and  when  found  in  both  there  was  generally 
some  difference  in  their  extent.  In  rather  less  than  one  tenth 
they  were  equally  large  on  both  sides,  and  in  another  tenth 
their  dimensions,  whether  moderate  or  small,  were  equally 
distributed. 

26.  By  the  term  "  vast  excavations  "  we  understand  those 
whose  capacity  equals  the  volume  of  a  goose's  egg,  a  man's 
closed  hand,  or  is  even  still  larger.  They  existed  either  in  the 
right  or  left  lung  in  the  proportion  of  about  one  half  of  the 
cases,  and  were  equally  frequent  on  either  side.  The  exca- 
vations of  "  moderate  size''  may  be  represented  by  a  middle 
sized  apple,  or  were  rather  smaller  ;  the  "  small  ones"  by  a 
hazel  nut  ;  both  were  nearly  equally  distributed  through  the 
remainder  of  the  cases. 

27.  The  contents  of  the  excavations  were  subject  to  varia- 
tion from  many  causes,  among  the  principal  we  may  mention 
their  chronicity,  — the  structure  of  the  cavities,  and  perhaps 
the  state  of  the  circulation  shortly  preceding  death.  If  they 
were  of  recent  origin,  their  contents  were  thick,  yellowish, 
similar  to  common  pus.  If  of  longer  duration  and  their  pa- 
rietes  were  broken  up  and  deprived  of  false  membrane,  the  fluid 
was  of  a  greyish  greenish  tint,  having  a  dirty  and  disagreeable 
appearance,  thin,  of  moderate  consistence,  and  sometimes 
tinged  with  blood,  or  even  of  a  deep  red  color.  This  last 
coloration  certainly  took  place  but  a  few  hours  before  death, 
for  we  frequently  found  it  at  the  post  mortem  examination, 
while  it  was  extremely  rare  to  see  similarly  colored  expecto- 
ration either  during  the  last  one  or  two  days  of  the  pa- 
tient's life. 


22  PATHOLOGICAL    ANATOMY.  LUNGS  ;  [Part  I, 

Though  in  general  the  contents  of  the  excavations  were 
without  any  particular  smell,  it  sometimes  closely  resem- 
bled that  of  animal  substances  after  they  have  been  some  time 
macerated.  This  was  independent  of  the  extent  of  the  cavities, 
for  the  odor  was  sometimes  absent  in  those  which  occupied  a 
fourth  or  fifth  part  of  the  volume  of  one  of  the  lungs.  Neither 
was  it  owing  to  contact  with  the  air,  or  at  least  this  was  not 
the  only  cause,  for  though  the  excavations  were  constantly 
partially  filled,  the  odor  was  only  observed  in  three  cases.  In 
one,  the  preceding,  it  seemed  to  result  from  the  gangrene  of 
some  fragments  of  grey  matter  incompletely  separated  from 
the  sides  of  the  cavity.  In  two  others,  this  particular  dis- 
position did  not  exist,  the  excavations  were  more  or  less  rug- 
ged in  their  structure,  without  any  other  peculiarity. 

28.  Instead  of  air  or  pus,  in  one  instance  we  found  an 
organized  fibrous  body,  filling  a  moderately  sized  tuberculous 
excavation.  This  fact  appears  to  us  of  sufficient  interest  to 
merit  notice  at  the  present  moment. 


SECOND    OBSERVATION. 

A  STROLLING  Organ  player,  set.  29,  of  a  moderately  strong 
constitution,  middle  stature  and  impetuous  disposition,  was  ad- 
mitted into  the  hospital  of  La  Charité,  April  24th,  1824.  He 
had  been  ill  a  year  and  eight  months  ;  had  ceased  his  usual 
occupation  for  twelve  months,  keeping  his  bed  occasionally 
during  the  last  three  weeks.  He  attributed  his  complaint  to 
having  taken  a  glass  of  cold  water  when  over-heated.  It  had 
commenced  by  a  dry  cough  and  dyspnoea  ;  no  expectoration 
before  the  second   month  of  its  duration,  and  until  the  last 


Chap.   1.]  ORGANISED    MASS    IN    CAVITY. 


23 


eight  days  he  had  never  had  haemoptysis.  At  this  period  he 
was  suddenly  attacked  without  any  previous  fit  of  coughing, 
and  when  he  was  walking  quietly,  with  so  copious  a  hasmoptysis 
that  he  is  confident  he  vomited  twenty-four  ounces  of  blood  in 
less  than  twenty  minutes  ;  after  which  the  sputa  only  presented 
a  variably  intense  red  color.  Rigors,  increased  heat  and  per- 
spirations the  last  nine  months.  Very  slight  diminution  of  the 
appetite,  though  vomiting  produced  by  cough  was  frequent. 
Diarrhœa  at  long  intervals,  lasting  a  few  days  each  time. 
Loss  of  flesh  from  the  commencement. 

On  the  25th  August,  marked  emaciation  ;  skin,  of  a  light 
yellow  color,  especially  that  of  face  ;  some  oppression  ;  cough, 
not  very  frequent  ;  expectoration,  opaque,  tinged  with  blood, 
or  of  a  mahogany  color.  The  patient  thinks  he  can  feel  the 
sputa  detach  themselves  from  the  left  side  of  chest,  and  at 
every  shock  caused  by  the  cough  he  experiences  a  slight  pain 
at  the  lower  part  of  the  same  side  ;  he  has  complained  of  this 
from  the  commencement.  Percussion  perfectly  flat  for  about 
two  inches  under  the  right  clavicle  ;  equally  soon  the  left  side, 
over  the  whole  of  the  part  corresponding  to  the  upper  lobe.  In 
the  same  regions  well  marked  pectoriloquy  ;  tracheal  respiration 
and  on  the  left  side  considerable  gurgling  râle.  Auscultation 
between  the  shoulders  gave  the  same  result.  Pulse,  rather 
quick,  small  and  weak  ;  temperature,  rather  less  than  natural  ; 
some  appetite  ;  thirst,  not  increased  ;  digestion,  easy  ;  abdo- 
men, yielding  and  not  painful  ;  one  stool  daily,  and  of  good 
consistence. 

(Pectoral  infusion  ;  gum   potion  ;  quarter  of  house  allow 
ance  ;  no  wine.) 

Sept.  1st.  Appetite,  increased  ;  pains  in  the  left  side  more 
severe  and  more  constant  than  usual.  In  the  evening  they  had 
diminished  in  intensity  ;  but  he  was  attacked  with  rather  acute 


24  PATHOLOGICAL    ANÂTOMY. LUNGS  ;  [Part  I, 

pains  in  hypogastrium  and  throat  ;  oppression  as  before  ;  no 
sensible  change  in  the  expectoration.  The  patient  referred  all 
his  sufferings  to  the  left  side  of  chest.  No  alteration  of  voice, 
and  no  painful  sensation  felt  in  trachea. 

On  the  11th,  the  respiration  became  more  embarrassed,  and 
during  the  night  he  was  obliged  to  retain  the  sitting  posture, 
and  afterwards  to  leave  his  bed  for  the  purpose  of  relieving 
the  dyspnœa.  On  the  morning  of  the  12th,  he  experienced 
behind  the  left  clavicle  a  very  extraordinary  sensation,  which 
he  compared  to  that  of  a  hole  (un  trou)  being  there.  The 
dyspnœa  was  extreme,  very  little  appetite,  stools  regular  and 
of  good  consistence.  He  complained  of  acute  pains  in  the 
abdomen,  remained  seated  on  a  chair,  the  body  inclined  for- 
wards and  suffering  great  anxiety. 

These  symptoms  continued  ;  the  breathing  became  very 
hurried  ;  appearance  of  sputa  unaltered  ;  occasional  variation 
in  intensity  of  the  abdominal  pains  ;  and  he  expired  in  the  night 
of  the  16th,  without  having  manifested  any  delirium.  He  got 
up  unassisted  on  the  morning  of  the  16th  to  relieve  the  dys- 
pnœa. During  the  day  and  the  previous  evening  we  could 
not  detect  pectoriloquy  under  the  left  clavicle  ;  the  patient 
said  that  he  had  heard  a  frightful  rattling  sound  in  the  same 
point  twenty-four  hours  earlier. 

Opening  of  the  corpse  thirty-two  hours  after  death. 

Exterior.  —  Extreme  emaciation.  Nothing  else  remark- 
able. 

Head.  —  A  thin  layer  of  infiltration  beneath  the  upper  por- 
tion of  the  arachnoid  ;  a  spoonful  of  clear  serous  fluid  in  each 
lateral  ventricle  ;  a  similar  quantity  in  the  base  of  the  skull. 
The  septum  lucidum  was  softened  and  pulpy,  as  it  were,  at 
its  inferior  part  :  the  remainder  of  cerebral  mass  healthy. 


Chap.   1.]  ORGANISED    MASS    IN    CAVITY.  25 

Neck.  —  No  alteration  of  epiglottis  or  larynx.  Mucous 
membrane  of  trachea  of  a  pale,  delicate  red,  interspersed  in- 
feriorly  with  pretty  numerous  ulcerations,  the  larger  of  which 
were  situated  on  its  fleshy  portion. 

Thorax.  —  The  left  lung  was  intimately  adherent  to  the 
costal  pleura  at  its  apex,  and  in  the  rest  of  its  extent,  by  means 
of  cellular  filaments,  in  the  intervals  of  which  there  was  slight 
serous  infiltration.  The  upper  lobe  was  indurated,  converted 
into  a  grey,  semi-transparent  matter,  in  the  centre  of  which 
existed  another  substance  of  perfectly  uniform  structure,  of 
yellowish  color,  and  similar  at  first  sight  to  jelly,  but  much 
firmer  and  not  easily  yielding  to  pressure.  Here  and  there 
were  seen  some  softened  tubercles,  more  or  less  excavated, 
and  in  the  upper  part  of  the  same  lobe  there  was  an  excava- 
tion capable  of  containing  a  middle-sized  apple,  filled  by  a  mass 
of  fibrine  which  was  red,  firm,  enveloped  in  a  white,  easily 
torn,  false  membrane,  slightly  adhering  to  the  one  lining  the 
cavity,  and  giving  off  numerous  septa  reuniting  in  a  central 
point.  Round  the  excavation  and  in  the  middle  of  the  grey 
substance  were  vessels  of  about  half  a  line  (un  millimètre),* 
or  rather  less  in  diameter.  We  traced  them  very  easily  by 
means  of  a  fine  wire,  but  without  detecting  any  communica- 
tion with  the  excavations  just  described.  A  tolerably  large, 
cord-hke  prolongation,  situated  between  this  cavity  and  a  much 
smaller  one  situated  posteriorly  to  it,  contained  a  small  vascular 
ramification,  which  also  did  not  seem  to  open  into  the  cavity. 
A  large  quantity  of  grey  matter,  tubercles  and  granulations 

*  The  unity  of  French  measures  is  the  metre  =  39.37079  English  inches  ; 
the  millimètre  is  =;  0.039  inches.  The  French  inch  is  divided  into  12  lines, 
and  there  are  443^  lines  in  the  metre  ;  so  that  a  millimetre  is  regarded  as 
about  the  l-26th  of  an  inch.  —  Cowan. 


26  PATHOLOGICAL    ANATOMY. LUNGS  ;  [Parti 

existed  in  the  lower  lobe,  half  of  which  was  still  penetrable 
by  air.  Cellular  adhesions  over  the  whole  surface  of  the  right 
lung  :  at  its  summit  there  were  numerous  grey  granulations, 
and  a  moderately  sized  excavation,  at  the  base  of  which  were 
some  isolated  portions  of  hepatized  tissue.  Heart  and  aorta, 
perfectly  sound. 

Abdomen.  —  Liver,  of  a  dull  red  color,  more  strongly 
marked  than  natural,  of  usual  dimensions.  Bile  in  the  gall- 
bladder of  moderate  consistence.  Mucous  membrane  of 
stomach  covered  with  a  viscid  mucus,  and  of  rather  a  bright 
red  color  throughout  its  whole  extent  ;  of  natural  thickness 
and  consistence  ;  its  villous  appearance  distinct.  Duodenum, 
natural.  Mucous  membrane  of  small  intestine,  as  if  sprinkled 
with  minute  particles  of  fat,  in  other  respects  healthy.  That  of 
the  large  intestine  was  a  little  softened  and  somewhat  injected 
throughout.  Four  small  ulcerations  in  caecum  and  ascending 
colon,  of  a  greyish  color,  caused  by  the  slightly  thickened 
cellular  tissue  which  formed  their  bottom.  The  fasces  pre- 
sented a  dull,  dirty  yellow  appearance  in  the  caecum,  but  were 
elsewhere  of  a  clear  yellow  color  and  good  consistence.  The 
other  viscera  of  abdomen,  healthy. 

29.  Were  we  merely  to  fix  our  attention  upon  the  apparent 
organization  of  the  fibrous  clot  occupying  the  large  excavation 
of  the  left  lung,  we  ought,  perhaps,  to  date  its  origin  from  the 
period  in  which  the  patient  experienced  a  copious  haemop- 
tysis. But  if  we  recollect  the  signs  furnished  by  auscultation, 
and  the  symptoms  observed  near  the  termination  of  the  affec- 
tion, this  will  appear  very  doubtful.  For  the  first  time  that 
we  saw  the  patient,  eight  days  after  the  occurrence  of  the 
haemoptysis,  pectoriloquy  could  be  distinctly  heard  under  the 
clavicle,  that  is,  immediately  in  the  point  corresponding  to  the 


Chap.   1.]  PORTION    OF»  THEM    IN    CAVITY.  27 

cavity,  filled  by  the  fibrous  coagulum,  and  this  we  heard  for 
many  days  in  succession.  We  attempted  in  vain  to  discover  it 
twenty -four  to  forty-eight  hours  previous  to  death.  By  the  sup- 
position that  the  fibrous  clot  was  formed  during  the  last  days  of 
existence,  all  would  be  easily  explained.  In  this  case,  pecto- 
riloquy ought  to  have  existed  under  the  left  clavicle  at  the  time 
of  admission,  and  ought  to  have  ceased  at  a  much  later  period. 
But  the  contrary  idea  leaves  every  thing  unexplained,  and 
forces  the  admission  that  pectoriloquy  may  or  may  not  be 
present  in  a  completely  filled  excavation.  If  we  join  to  these 
considerations  the  sudden  appearance  of  other  local  symptoms, 
the  dyspnœa,  the  extraordinary  sensation  complained  of  be- 
hind the  left  clavicle  four  days  before  death,  we  must  admit, 
notwithstanding  the  difficulty  of  giving  any  explanation  of 
these  subsequent  accidents,  that  it  is  infinitely  probable  that 
the  formation  of  the  fibrous  coagulum  took  place  during  the 
last  period  of  the  patient's  life.  With  regard  to  the  dyspnœa, 
it  may  be  remarked  that  the  state  of  the  mucous  membrane 
of  the  stomach  and  colon,  which  we  may  consider  as  produced 
by  acute  inflammation,  had  no  doubt  a  greater  or  less  influ- 
ence in  its  production  (98,  341). 

30.  We  have  very  recently  met  with  a  fact  of  another  de- 
scription, and  much  more  remarkable.  It  is  connected  with 
the  particular  subject  at  present  before  us,  and  we  shall  now 
relate  it. 


THIRD     OBSERVATION. 

A  SEMPSTRESS,  Set.  27,  of  rather  delicate  constitution,  was 
confined  without  accident,  and  at  the  natural  period,  fifteen 


28  PATHOLOGICAL    ANATOMY. LUNGS  ;  [Part  I J 

days  before  entering  the  hospital  of  La  Charité,  March  8th, 
1825.  She  had  coughed  and  expectorated  the  last  seven 
months  and  a  half  without  any  apparent  cause  and  was  subject 
occasionally  to  pains  in  the  side.  Rigors,  followed  by  heat 
and  sweatings,  had  been  complained  of  during  the  last  periods 
of  pregnancy,  but  had  ceased  after  parturition.  Complete 
anorexia  ;  thirst  rather  urgent  the  last  month  ;  and  for  the  last 
three  months  there  had  been  almost  constant  diarrhoea.  She 
had  not  had  haemoptysis,  and  could  not  recollect  when  she 
first  began  to  lose  her  flesh. 

On  the  9th  of  March  we  observed  loss  of  color  over  the 
whole  body,  extending  to  lips  ;  considerable  feeling  of  lassi- 
tude ;  movements  of  body,  painful,  rarely  made  and  of  lim- 
ited extent  ;  lies  with  head  raised  ;  considerable  oppression  ; 
cough,  not  frequent  ;  expectoration  mucous  and  semi-opaque. 
Percussion  of  chest  clear  every  where  ;  a  gurgling  sound 
heard  under  right  axilla  and  posteriorly  between  the  shoulder 
and  vertebral  column  of  the  same  side:  Inferiorly  and  to  the 
left  in  the  corresponding  part  was  a  slight  crepitous  râle.  In 
other  parts,  respiratory  murmur,  natural.  Pulse,  small,  weak, 
accelerated  (one  hundred  and  ten  in  a  minute)  ;  heat  of  sur- 
face, moderate  ;  tongue,  pale  and  clean  ;  mouth,  clammy, 
complete  anorexia,  no  nausea.  Epigastrium,  and  especially 
the  hypogastrium,  painful  ;  pain,  much  increased  by  pressure. 
The  patient  had  lost  very  little  blood  after  her  dehvery. 
On  the  fourth  day  the  discharge  had  become  whitish,  and  had 
continued  so  since  ;  it  was  not  abundant. 

(Sweetened  infusion  of  violet  ;  gum  potion  ;  flaxseed  tea 
cnemata  ;  emollient  fomentations  upon  hypogastrium  j  a  half- 
julep  ;  yolk  of  egg  mixed  with  water.) 

Until  the  5th  of  April,  the  day  of  her  death,  the  thirst  was 
moderate,  more  complained  of  at  night  than  during  the  day  ; 


Chap.  1.]  PORTION    OF    THEM    IN    CAVITY.  29 

expectoration,  scanty,  and  only  opaque  and  nummulated 
(pelotonnés)  in  the  last  twenty-four  hours.  In  the  night  of 
the  25th  of  March,  an  acute  pain  was  felt  in  the  left  side  of 
chest,  readily  yielding  to  the  application  of  a  few  leeches. 
From  that  moment  there  was  considerable  cough  and  oppres- 
sion. Up  to  this  period  percussion  and  auscultation,  though 
frequently  repeated,  merely  confirmed  the  results  of  the  first 
examination.  The  pulse  was  constantly  small  and  weak, 
varying  from  a  hundred  and  eight  to  a  hundred  and  fifteen. 
The  patient  was  attacked  with  a  violent  rigor  in  the  night  of 
the  25th  of  March  ;  and  from  this  time  a  sensible  increase  of 
general  temperature  took  place.  We  never  remarked  any 
perspirations. 

The  thirst  was  not  urgent  ;  appetite,  quite  gone.  After  the 
13th  of  March  there  were  nausea  and  vomiting  of  green,  bitter 
substances,  or  almost  tasteless  and  whitish,  either  during  the 
cough  or  in  its  intervals.  This  vomiting  occasionally  ceased 
for  a  day  or  two,  but  it  sometimes  occurred  several  times  in  the 
twenty-four  hours.  The  pains  felt  in  abdomen  diminished  in 
intensity.  No  diarrhoea  until  the  last  week  ;  it  was  then  con- 
siderable, but  unaccompanied  with  colic.  The  urine  became 
more  or  less  burning,  and  from  the  28th  of  March  to  the  2d  of 
April,  a  complete  retention  took  place,  requiring  the  frequent 
introduction  of  the  catheter.  The  discharge  from  vagina  be- 
came red  for  a  short  time  at  two  different  periods. 

The  prostration  diminished  four  days  after  the  entrance  of 
patient  into  the  hospital,  and  the  countenance  became  more 
animated. 

On  the  12th  of  March  we  observed  slight  œdema  of  lower 
extremities,  which  rapidly  increased. 

On  the  25th,  she  complained  of  pains  in  the  thighs,  which 
were  very  acute  in  the  inner  and  upper  part  of  left,  two  days 


30  PATHOLOGICAL    ANATOMY.  LUNGS  ;  [Parti, 

before  death,  and  the  skin  of  the  part  had  a  slight  red  tinge. 
Constant  dehrium  and  general  agitation  during  the  last  night. 
Death  took  place  at  four,  a.  m. 

In  addition  to  the  first  prescription,  an  infusion  of  the  triti- 
cumrepens  with  the  syrup  of  the  five  roots  and  aromatic  fumi- 
gations under  the  bed  clothes  with  juniper  berries  were  had 
recourse  to.  For  the  diarrhoea,  the  white  decoction  with 
quince  syrup,  some  diascordium  and  a  grain  of  opium,  with  a 
narcotic  enema  afterwards,  were  prescribed.  The  only  nour- 
ishment taken  was  the  yolk  of  eggs  with  water. 

Opening  of  the  corpse  twenty-eight  hours  after  death. 

Exterior.  —  Inferior  extremities  much  infiltrated  ;  some 
phlyctenas  at  the  inner  and  upper  part  of  thighs,  where  the 
skin  was  of  rather  a  bright  red  color.  The  crural  veins,  and 
especially  those  of  the  left  side,  were  distended  with  firm, 
fibrous  coagula  of  variably  intense  red  color,  either  hema- 
tite or  mahogany  color,  and  adhering  firmly  to  the  lining 
membrane,  which  was  of  a  dehcate  rose  color  and  rather 
thicker  than  that  of  another  individual  of  the  same  age,  v/ith 
which  we  compared  it.  The  coagula  extended  into  the  col- 
lateral and  iliac  veins  as  far  as  the  vena  cava  superior. 

Head.  —  Tolerably  abundant  infiltration  beneath  the  arach- 
noid covering  the  convexity  of  the  hemispheres.  Not  quite 
a  spoonful  of  clear  serous  fluid  in  each  lateral  ventricle  ;  a 
spoonful  and  a  half  of  the  same  fluid  in  the  inferior  occipital 
fossae.     The  whole  of  the  encephalic  mass  rather  soft. 

Neck.  —  One  of  the  lymphatic  glands  on  the  left  side  had 
acquired  the  size  of  an  almond  in  its  husk,  was  firm  in  texture, 
of  reddish  color,  and  spotted  with  numerous  small,  yellow 
opaque  bodies,  evidently  tuberculous.  No  change  was  ob- 
served in  the  epiglottis,  larynx,  or  trachea. 


Chap.   1.]  PORTION    OF    THEM    IN    CAVITY.  31 

Chest.  —  About  two  quarts  of  clear  serous  and  slightly 
red  fluid  were  found  in  the  cavity  of  left  pleura.  The  corres- 
ponding lung  was  much  diminished  in  volume,  and  invested, 
as  was  the  costal  pleura,  by  a  red  false  membrane,  moderately 
consistent,  and  rather  less  than  half  a  line  in  thickness.  The 
substance  of  the  lung  was  greyish,  but  healthy  and  free  from 
air  ;  bronchia,  of  a  bright  red  color,  without  sensible  thick- 
ening. The  right  lung  presented  some  thinly  scattered  cellu- 
lar adhesions,  and  in  its  summit  an  excavation  of  middle 
dimensions,  partly  filled  by  a  muddy  and  greenish  fluid,  which 
surrounded  a  slightly  greyish  colored  mass,  streaked  with 
black  lines  similar  to  those  we  observe  in  the  pulmonary 
tissue  ;  its  form  was  oblong,  a  little  flattened,  sixteen  lines 
long  and  ten  wide  ;  it  weighed  very  little,  was  soft  and  rather 
elastic,  and  of  a  pale  rose  color  internally  ;  it  was,  in  fact, 
exactly  similar  to  a  fragment  of  the  lung  itself  after  it  has  been 
immersed  some  time  in  water.  There  was  no  bad  odor,  or 
any  pedunculated  prolongation  at  its  surface.  The  excava- 
tion was  lined  by  a  false  membrane  of  moderate  consistence, 
a  quarter  of  a  line  in  thickness,  and  lying  upon  healthy  pul- 
monary tissue.  It  presented,  in  opposite  points,  two  projec- 
tions, of  about  a  line  in  height,  formed  by  the  extremities  of 
two  bronchial  ramifications.  The  remainder  of  the  lung  was 
slightly  engorged,  free  from  tubercles  or  grey  granulations,  or 
any  other  trace  of  organic  disease.  The  bronchia  were  pale 
and  thin. 

The  heart  was  scarcely  two-thirds  of  its  usual  size  ;  aorta, 
healthy. 

Abdomen.  —  About  a  quart  of  clear  lemon  colored  fluid  in 
the  peritoneal  cavity.  The  stomach,  of  nearly  twice  its  ordi- 
nary volume,  partly  filled  the  left  hypochondrium,  reaching  to 
the  umbilicus.      Its  mucous  membrane  was  of  a  yellowish 


32  PATHOLOGICAL    ANATOMY. LUNGS  ;         [Part  I, 

brown  color  in  the  whole  of  its  extent,  with  the  exception  of  a 
zone  in  the  vicinity  of  the  pylorus  of  about  an  inch  in  width  ; 
its  consistence  was  moderate,  and  it  was  about  half  its  usual 
thickness.  It  was  still  thinner  in  the  points  corresponding  to 
numerous  whitish,  rounded  spots,  from  one  to  two  lines  wide, 
almost  uniformly  distributed  over  its  whole  surface.  Mucous 
membrane  of  small  intestine,  healthy  ;  that  of  caecum  and 
colon  a  little  softened.  In  the  remaining  portions  of  the  large 
intestine  it  was  as  soft  as  mucus,  and  it  was  red  in  the  rectum 
only.  No  ulcerations.  Mesenteric  and  mesocolic  glands, 
healthy.  The  uterus  was  twice  as  large  as  usual  ;  its  cavity 
much  increased,  of  blackish  color  ;  its  substance  more  or  less 
red,  and  as  if  spongy  to  the  touch  and  easily  broken  down  ; 
its  parietes  were  not  sensibly  thickened,  except  anteriorly, 
where  they  projected  about  a  line  on  the  inner  surface.  The 
ovaries  were  rather  soft  and  larger  than  natural.  The  remain- 
der of  abdominal  viscera,  sound. 

31.  The  presence  of  a  fragment  of  pulmonary  tissue  in  the 
midst  of  an  excavation  is  certainly  a  very  extraordinary  fact, 
and  which,  perhaps,  up  to  the  present  moment,  has  not  been 
observed.*  There  could  be  no  doubt  as  to  the  real  nature  of 
what  we  have  just  described  ;  for  the  color,  the  consistence, 
the  structure,  the  mode  of  tearing,  —  in  short,  every  thing  cor- 
responded with  what  characterizes  the  tissue  of  the  lung  itself. 
The  absence  of  gangrenous  odor  proved  that  its  complete  sepa- 
ration was  rather  recent,  and  we  may  very  well  suppose  that  it 

*  If  we  may  trust  the  descriptions  of  Tulpius  in  his  Observations  JHedi- 
ctB,  1641  ;  of  Aretaeus,  in  his  chapter  "  On  Abscesses  of  the  Lungs  ;"  of 
Galen,  and  of  Bontius  in  his  Medicina  Indorum,  1G31,  the  expectoration  of 
portions  of  the  lung  and  bronchia  is  not  very  uncommon.  Vide  Young  on 
Consumption,  pages  124,  139,  167.  —  Cowan. 


Chap.    1.]  PORTION    OF    THEM    IN    CAVITY.  33 

adhered  for  some  time  to  the  remainder  of  the  organ  by  the 
two  bronchial  projections  already  described.  Indeed,  these 
two  points  were  the  only  ones  where  no  false  membrane  ex- 
isted, while  every  where  else  the  latter  was  continuous  with 
itself;  indicating,  no  doubt,  that  the  separation  of  the  frag- 
ment had  been  effected  some  time,  with  the  exception  of  the 
two  projecting  bronchia. 

This  excavation  was  remarkable  also,  on  account  of  the  false 
membrane  which  lined  it  being  every  where  in  contact  with 
healthy  or  only  slightly  engorged  pulmonary  tissue,  which  is 
very  rarely  the  case. 

32.  But  may  it  not  be  asked,  with  some  apparent  proba- 
bility, whether  this  excavation  really  was  the  effect  of  tubercles, 
and  if  the  patient  had  phthisis  ;  for  no  tubercles  or  grey  granu- 
lations existed  in  the  lungs  ;  there  were  no  ulcerations  in  the 
larynx,  trachea,  or  intestines,  —  alterations  so  frequently  occur- 
ring in  this  affection  ?  To  this  we  would  reply,  that  the  puru- 
lent matter  of  the  excavation  was  exactly  similar  to  what  we 
usually  find  in  tuberculous  cavities  ;  that  the  false  membrane 
had  equally  analogous  properties  ;  lastly,  and  this  fact  is  per- 
haps one  of  the  most  conclusive,  a  cervical  gland  was  evidently 
tuberculous,  and  in  the  course  of  these  researches  we  shall 
find  that  we  have  never  observed  the  tuberculisation  of  lym- 
phatic glands,  except  in  phthisical  patients.* 

*  This  mode  of  reasoning  being  probably  rather  new  to  the  reader,  we 
refer  him  to  the  one  hundred  and  fifty-eighth  section  for  itssoUition.  If  ob- 
servation has  demonstrated  (and  we  beheve  it  has),  that  after  the  age  of 
fifteen  tubercles  in  any  organ  of  the  body  involve  their  presence  in  the 
lungs,  the  conclusions  of  the  author  are  both  legitimate  and  necessary, 
though  without  this  previous  rigorous  observation,  they  would  have  been 
impossible.  —  Cowan. 

E 


34  PATHOLOGICAL    ANATOMY. LUNGS  ;  [Partly 

Among  the  facts  of  this  observation,  over  which  we  shall 
merely  glance,  we  would  recall  the  pleurisy  of  the  left  side, 
the  invasion  of  which  was  marked  by  pretty  acute  pains  ;  the 
partial  and  general  diminution  in  thickness  of  the  mucous 
membrane  of  the  stomach,  without  well  marked  softening  ; 
the  want  of  consistence,  and  the  change  of  color  of  the  uterus, 
produced  by  inflammation  ;  finally,  the  œdema  of  the  lower 
extremities,  which  must  be  attributed  to  the  obstruction  of  the 
crural  veins. 

33.  For  the  purpose  of  terminating  all  we  intend  to  remark 
on  the  subject  of  tuberculous  excavations,  it  may  be  added, 
that  in  no  one  instance  have  we  met,  surrounded  by  healthy 
pulmonary  parenchyma,  with  cavities  communicating  with  the 
bronchia,  and  lined,  as  are  tuberculous  excavations  of  long 
standing,  with  a  false  membrane  of  a  light  grey  color,  semi- 
cartilaginous  and  semi-opaque.  Such,  however,  have  been 
observed  by  M.  Laennec,  in  the  examination  of  persons  who 
had  presented  the  symptoms  of  phthisis  during  a  space  of 
time  more  or  less  considerable  ;  and  judging  from  their  struc- 
ture, it  would  be  difficult  not  to  believe  that  tuberculous  sof- 
tening preceded  their  formation.  The  previous  observation 
is  indeed  well  adapted  for  the  confirmation  of  this  fact.  For 
here,  as  in  the  other  cases  we  are  referring  to,  there  was  but 
a  single  excavation  ;  the  pulmonary  tissue  was  healthy  ;  and 
we  may  conclude,  that  if  the  life  of  the  individual  had  been 
prolonged  for  some  weeks  or  months,  the  false  membrane 
lining  the  cavity  would  have  presented  the  characters  we  have 
last  mentioned. 

We  have  also  failed  to  meet  at  the  apex  of  the  lungs  with 
those  masses  of  condensed  cellular  tissue,  in  which  the  bron- 
chial ramifications,  more  or  less  dilated,  terminate,  and  which 


Chap.   1.]  CICATRICES    OF    CAVITIES.  35 

are   considered   by  Laennec  as   the  cicatrices  of  tuberculous 
cavities.* 

34.  The  depressions  observed  in  the  upper  part  of  the 
lungs,  around  which  their  tissue  is,  as  it  were,  puckered,  do 
not  appear  to  depend  upon  any  determinate  lesion.  We  have 
frequently  seen  them  when  the  pulmonary  parenchyma  was 
healthy,  or  only  slightly  indurated  to  a  small  depth,  imme- 
diately beneath  the  pleura.  They  were  present  also  some- 
times when  either  crude  tubercles,  small  excavations,  or  osse- 
ous concretions  existed  in  the  summit  of  the  lungs. 

35.  We  have  never  found  bronchial  ramifications  in  the 
interior  of  tuberculous  cavities,  or  in  the  masses  of  the  grey, 
semi-transparent  matter,  so  that  the  first  effect  of  the  develop- 
ment of  this  substance  appears  to  be,  as  M.  Laennec  has 
remarked,  the  destruction  of  the  bronchia.  It  might  be  thought 
that  this  destruction  arises  from  the  transformation  of  the  air 
tubes  into  the  grey  or  tubercular  matter  ;  but  this  supposition 
appears  to  us  very  doubtful,  from  the  fact,  that  we  have  never 

*  These  results  are  singularly  negative,  when  compared  with  those  of  M. 
Laennec,  Andral  and  others,  who  hring  forward  copious  and  undeniable 
evidence  of  cicatrization  of  tuberculous  excavations,  and  the  formation  of  a 
fibro-cartilaginous  membrane,  when  the  cavity  is  not  obliterated.  It  must 
be  recollected  that  M.  Louis  never  forces  his  conclusions  beyond  the  num- 
ber of  facts  he  is  analysing,  and  it  is  remarkable  that  not  one  of  these  has 
presented  an  example  of  cicatrization  ;  this  inclines  us  to  suppose  that  the 
presence  of  a  cicatrice  has  often  been  hastily  admitted  ;  a  supposition  con- 
firmed by  the  succeeding  observations  of  our  author.  That  a  tuberculous 
excavation  is  ever  capable  of  cure  is  an  important  fact,  and  highly  calculated 
to  encourage  us  in  the  research  of  means  which  may  tend  to  arrest  this 
hitherto  most  destructive  affection.  Vide  Andral,  CZm.  Med.  vol.  iii.  page 
382  ;  Laennec,  pages  299,  323, —  and  notes  by  Dr.  Forbes.  Cottereau,  ia 
tils  Essay  on  Chlorine  Inhalation,  adduces  also  some  incontestable  facta, 
—  Cowan. 


36  PATHOLOGICAL    ANATOMY. LUNGS  ;         [Part  I, 

seen  this  transformation,  either  near  the  excavations  or  the 
tubercular  masses,  or  in  any  other  part  of  the  lungs,  even 
where  the  bronchia  presented  various  alterations.  It  is,  then, 
highly  probable  that  this  destruction  takes  place  by  absorp- 
tion. 

36.  The  bronchial  mucous  membrane  sometimes  retained, 
in  the  neighborhood  of  tuberculous  cavities,  its  natural  pale- 
ness. In  general  it  was  of  a  bright  red  color,  and  this  seemed 
to  be  caused  by  the  continual  passage  of  the  purulent  secre- 
tion of  the  excavations  through  the  bronchia  ;  for  it  was  not 
present,  or  very  rarely  so,  near  the  masses  of  grey  or  tuber- 
culous matter  not  yet  in  suppuration  ;  it  was  less  frequent  in 
the  bronchia  communicating  with  recent  than  with  old  excava- 
tions, and  when  existing  throughout  the  lung,  it  was  not  more 
marked  around  the  latter  than  elsewhere.* 

37.  When  reddened,  the  bronchial  mucous  membrane  was 
sometimes  a  little  thickened,  and  occasionally  the  seat  of  small 
ulcerations.  But  much  more  frequently  there  was  dilatation  of 
the  air-tubes,  and  hypertrophy  of  all  their  tunics.  This  hyper- 
trophy was  especially  marked  in  the  upper  part  of  the  lungs, 
where  the  bronchia  were  often  three  or  four  times  thicker  than 
natural  ;  and  it  is  easy  to  conceive  that  such  various  changes 
would  tend  to  augment  the  severity  of  the  principal  aiFection.  j* 

*  Numerous  facts  are  scattered  through  the  volume  tending  strongly  to 
corroborate  the  statement  that  the  redness  of  the  mucous  membrane  of  the 
air-tubes  and  its  ulceration  are  often  depending  on  the  contact  of  the  con- 
tents of  the  tuberculous  excavations.  The  fact  has  not  before  been  demon- 
strated, and  is  important  in  the  question  of  the  dependence  of  tubercles  on 
bronchitis.  —  Cowan. 

t  The  frequency  of  dilated  bronchia  in  the  upper  lobes  is  rather  in  oppo- 
sition to  what  we  know  of  the  progress  of  simple  bronchitis  from  below 
upwards  ;  it  might  naturally  be  expected  to  prevail  where  bronchitis  is  most 


Chap.   1.]  INFLAMMATION    OF.  37 

38.  Inflammation  of  the  'pulmonary  parenchyma  was  not 
rare.  We  have  observed  it  at  the  second  stage,  in  a  very 
variable  extent  in  eighteen  subjects,  or  in  a  httle  less  than  one 
sixth  part  of  our  cases.  The  pulmonary  tissue  was  red,  con- 
tained no  air,  was  indurated  and  granulated,  in  a  word,  hepa- 
tized  ;  and,  almost  constantly,  the  hepatization  existed  in  the 
lower  lobe.  In  nine  subjects  it  occupied  a  considerable  space, 
from  the  half  to  three  fourths  of  one  of  the  lungs.  In  the 
others  it  was  much  more  limited,  and  presented  the  appear- 
ance of  small  masses  more  or  less  disseminated.  The  exca- 
vations were  very  considerable  in  four  of  the  first-mentioned 
class.  In  the  others,  there  were  either  merely  semi-trans- 
parent granulations  or  tubercles  partially  excavated.  The 
characters  of  the  alteration  indicated  a  recent  disease  ;  and  the 
history  of  the  symptoms  proved,  as  we  shall  see  farther  on 
(286),  that  it  had  only  preceded  death  a  few  days. 

frequent,  viz.,  in  the  lower  lobes.  Does  the  physical  condition  of  the  up- 
per portion  of  the  lung  exert  any  intluence  on  this  morbid  peculiarity  ?t  — 
Cowan. 

X  1  doubt  the  fact  which  the  translator  gives  as  the  basis  of  the  previous 
remark.  If  the  reader  will  observe,  Louis  does  not  say  dilatation  of  the 
bronchia  is  most  frequent  in  the  upper  lobes,  but  merely  that  hypertrophy 
(èpaississement)  of  their  different  textures  is  especially  marked  in  the  upper 
part  of  the  lungs.  Again,  I  have  a  positive  fact  which  tends  to  prove  that 
dilatation  of  the  bronchia  is  more  common  below  than  above.  In  my  notes 
taken  of  Louis's  lectures,  delivered  at  La  Pitié,  I  find  mentioned,  in  two 
different  places,  in  the  lecture  upon  dilatation  of  the  bronchia,  and  in  that 
upon  the  causes  of  phthisis,  the  following  data.  Out  of  twenty  cases  of  dila- 
tation of  the  bronchia,  nine  had  dilatation  towards  the  base  of  the  lungs  ; 
five  towards  the  upper  parts  ;  six  had  general  dilatation  throughout  the 
lungs.  I  cannot  doubt,  therefore,  that  the  translator  has,  by  chance,  given 
an  erroneous  view  of  the  text,  and  rests  upon  false  presumptions,  when  he 
spsaksof  the  "  frequency  of  dilated  bronchia  in  the  upper  lobes."  — H.  I.  B. 


38         PATHOLOGICAL  ANATOMY. LUNGS.    [Part  I, 

39.  We  have  found  a  state  of  simple  engorgement,  or  the 
first  degree  of  pneumonia,  in  twenty-three  subjects,  and 
usually  not  extensive.  In  four  cases  only  it  occupied  the 
greater  part  of  one,  or  even  of  both  lungs,  which  were  still 
crepitating,  giving  vent  on  incision  to  a  large  quantity  of  red 
frothy  fluid  ;  the  consistence  of  the  engorged  part  was  much 
diminished,  or  it  was  easily  torn. 

In  one  of  the  cases  where  a  considerable  portion  of  the  lung 
was  thus  affected,  we  observed  two  days  before  death  pain 
and  a  rather  fine  crepitation  in  the  affected  side.  These 
symptoms  confirm  the  inflammatory  nature  of  the  affection, 
and  indicate  here,  as  in  the  preceding  cases,  that  it  had  com- 
menced but  a  few  days  before  death. 

40.  The  development  of  this  complication  at  a  period  so 
shortly  before  death  is  not  peculiar  to  phthisical  cases.  We 
have  remarked  it  at  the  termination  of  other  chronic  diseases, 
and  in  nearly  equal  proportion.  In  one  hundred  and  twelve 
cases  where  death  took  place  during  the  last  stage  of  these 
affections,  in  twelve  we  found  a  portion  of  one  and  some- 
times of  both  lungs,  red,  granulated  and  hepatized.  A  state 
of  congestion  was  noticed  in  ten  other  instances  ;  and,  as  we 
have  shown  in  the  cases  of  phthisis,  the  history  of  the  symp- 
toms proved  the  inflammation  to  have  preceded  death  only  a 
few  days.  It  results  from  this  comparison  of  cases,  that  tuber- 
cles and  tubercular  excavations  are  nearly  without  influence 
over  the  development  of  pneumonia  in  the  last  stage  of 
phthisis.* 

*  Vide  Article  "  Pneumonia"  among  the  "  causes"  of  Phthisis. — Cowan. 


Chap.  l.J       pleura:  ;  false  membranes,  he.  39 


ARTICLE    II, 


PLEURiE. 


41.  Nothing  was  so  frequent  as  «é/Aesion  of  the  lungs  to 
the  pleurae  ;  for  in  one  hundred  and  twelve  cases  there  only 
existed  one  in  which  the  two  lungs  were  perfectly  free  in  the 
whole  of  their  extent.  We  have  only  found  the  right  lung 
connpletely  without  adhesions  eight  times  ;  the  left  only  seven, 
and  in  these  cases  there  were  either  no  tuberculous  excava- 
tions, or  only  those  of  very  limited  dimensions. 

In  twenty-five  other  cases,  the  adhesions  were  cellular, 
easily  ruptured,  confined  to  a  small  space,  and  seldom  present 
on  both  sides.  In  seven  out  of  this  number  there  was  no  ex- 
cavation in  the  lung  corresponding  to  the  adhesions  ;  in  ten 
others  the  cavities  were  small,  and  in  the  remaining  eight 
cases  they  were  of  moderate  or  very  considerable  size. 

Among  the  other  individuals  the  adhesions  were  universal, 
or  nearly  so  ;  formed  either  by  variably  dense  cellular  tissue, 
or  a  false  membrane  ;  in  both  which  cases  large  cavities  almost 
constantly  existed. 

ThuSi  there  was  evidently  some  relation  between  the  ex- 
tent of  organic  alteration  and  the  pleural  adhesions  ;  if  the 
latter  were  absent,  there  were  neither  large  nor  middle-sized 
excavations,  and  in  general  none  whatever.  Were  they  weak 
and  Umited  in  extent,  the  cavities  were  generally  very  small, 
rarely  large,  and  sometimes  altogether  wanting. 

Lastly,  where  the  adhesions  were  dense,  extensively  dis- 
tributed or  even  universal,  they  always  indicated  excavations 


40  PATHOLOGICAL    ANATOMY. PLEURA;  [Parti, 

in  the  lungs,  and  in  the  great  majority  of  cases  that  those  ex- 
cavations were  large,  or  at  least  of  considerable  size. 

42.  The  proportion  which  existed  between  the  size  of  the 
tuberculous  cavities  and  the  adhesions,  demonstrated  the  in- 
fluence of  the  first  upon  the  second.  The  large  excavations 
constantly  occupied  the  summit  of  the  lungs,  approximated 
closely  to  their  surface,  and  there  only  were  found  those  dense 
resisting  false  membranes  which  we  have  already  described 
(23),  as  either  strengthening  the  sides  of  the  cavity,  or  con- 
stituting them  over  a  certain  space.  This  mutual  relation 
between  cavities  and  adhesions  is  also  pointed  out  by  other 
facts.  Thus,  in  two  cases  where  the  lungs  only  contained 
two  masses  of  tuberculous  matter  immediately  beneath  the 
pleura,  the  adhesions  were  confined  to  these  points,  and  were 
formed  by  a  cellular  prolongation,  one  inch  and  a  half  long, 
and  of  the  same  size  as  the  tuberculous  masses. 

43.  We  have  twice  found  a  false  membrane  of  moderate 
consistence  lining  the  pulmonary  and  costal  pleurae,  converted 
into  tuberculous  matter  (Obs.  16).  Another  case  has  pre- 
sented us  with  an  example  of  the  same  transformation,  though 
of  very  limited  extent,  taking  place  in  a  false,  semi-cartilagi- 
nous membrane  which  enveloped  the  summit  of  one  of  the 
lungs. 

44.  These  adhesions  v^^ere  the  consequences  of  chronic  in- 
flammation of  variable  duration  ;  and,  as  we  shall  hereafter 
see,  the  period  of  its  commencement  could,  in  many  instances, 
have  been  determined  by  the  history  of  the  patients  (246). 

45.  In  cases  of  other  chronic  diseases  this  was  not  always 
the  fact,  and  in  the  majority  of  instances  we  were  unable  to 
assign  any  cause  for  the  adhesions  which  existed.  We  have 
found  them  thirty-five  times  out  of  one  hundred  and  ten,  and 
in  twelve  cases  they  were  universal,  either  on  both  or  only  on 


Chap.   1.]    FALSE    MEMBRANES  ;    TUBERCULOUS,   StC.  41 

one  side  of  the  chest.  Although  this  proportion  is  consider- 
able, it  is  still  very  inferior  to  what  we  find  in  cases  of  phthisis 
(41)  ;  an  additional  proof  of  the  influence  of  tubercles  in  the 
production  of  adhesions.  But  what,  under  this  point  of  view, 
is  altogether  peculiar  to  phthisis  is  the  semi-cartilaginous  en- 
velope covering  the  summit  of  the  lungs,  and  the  transforma- 
tion of  false  membranes  into  tuberculous  matter. 

46.  As  we  have  already  remarked  in  speaking  of  pneu- 
monia, the  invasion  of  pleurisy  coincides  in  a  large  proportion 
of  our  patients  with  the  last  days  of  life,  the  period  of  extreme 
weakness  and  emaciation.  We  have  observed  it  in  one  tenth 
of  the  cases.  The  lung  or  costal  pleura,  frequently  both, 
were  covered  to  a  greater  or  less  extent  by  a  soft,  yellowish, 
false  membrane  of  variable  thickness  ;  there  was  an  effusion 
of  a  certain  quantity  of  a  serous,  reddish  fluid,  limpid  or  other- 
wise, or  even  completely  purulent.  The  characters  of  the 
alteration  indicated  its  recent  nature,  and  the  history  of  the 
symptoms  proved  it  could  not  date  farther  back  than  nineteen, 
twelve,  eight,  or  three  days  before  death  (287). 

47.  Patients  dying  from  other  chronic  affections  have  pre- 
sented the  same  alterations,  preceded  by  similar  symptoms  in 
the  last  periods  of  life,  only  the  proportion  was  rather  less, 
one  thirteenth.  From  what  has  been  said,  we  may  con- 
clude that  pneumonia  and  pleurisy  are  frequently  developed  in 
the  last  period  of  phthisis  and  of  other  chronic  diseases  ;  some- 
times resulting  from  evident  causes,  as  the  application  of  cold 
to  the  surface  of  the  body,  but  most  frequently  without  any 
appreciable  origin.  Their  progress  is  rapid,  and  they  augment 
the  number  of  causes  which  hasten  the  death  of  consumptive 
patients  ;  they  also  form  another  argument  for  being  more 
watchful  in  our  treatment  of  protracted  cases,  when  near  their 

F 


42  PATHOLOGICAL    ANATOMY. TRACHEA  ;       [Part  Ij 

termination,  and  show  the  necessity  of  protecting  the  patient 
fronj  all  those  external  influences  calculated  to  produce  either 
of  the  complications  above  mentioned. 

48.  We  have  also  frequently  observed  in  the  cavity  of  the 
pleurae  an  effusion  of  clear  fluid,  in  quantity  from  a  quart  and 
upwards.  This  effusion,  which  took  place  in  the  tenth  part 
of  our  cases,  came  on  at  times  very  rapidly.  Of  this  we  were 
convinced  in  two  instances,  where  the  thorax  gave  every  where 
a  clear  sound  on  percussion  thirty-six  hours  before  death,  but 
where  two  quarts  of  clear  serum  were  afterwards  found  in  one 
side  of  the  chest. 

The  same  effusion  took  place  at  the  close  of  other  chronic 
diseases,  and  excepting  after  affections  of  the  heart,  was  pres- 
ent in  one  fourth  of  the  cases.  This  difference  of  proportion 
corresponds  to  what  we  have  remarked  with  regard  to  the  ad- 
hesions of  the  lungs  to  the  pleurae,  in  patients  dying  from 
phthisis  and  other  organic  affections.  It  seems  to  indicate  that 
this  species  of  hydrothorax  is  unconnected  with  the  nature  of 
the  disease. 


ARTICLE    III. 

EPIGLOTTIS,  LARYNX  AND  TRACHEA. 

49.  Of  these  three  continuous  organs,  parts  of  the  same 
apparatus,  very  analogous  in  their  structure,  and  susceptible  of 
the  same  alterations,  the  larynx  alone  has  attracted  the  atten- 
tion of  observers  in  the  history  of  phthisis.  Its  ulcerations 
have  been  described,  but  those  of  the  epiglottis  have  been 
scarcely  mentioned,  and  those  of  the  trachea  almost  entirely 
overlooked.  The  cause  of  this  omission  is  no  doubt  owing  to 
the  fact,  that  there  are  frequently  no  symptoms  whatever  to 


Chap.   1.]  ULCERATIONS.  43 

announce  this  alteration,  and  also  to  the  practice  among  many 
medical  men  of  examining  after  death  those  organs  only  whose 
functional  derangement  was  more  or  less  prominent  during  life. 
Be  this  as  it  may,  ulcerations  of  the  epiglottis  are  not  uncommon 
in  phthisis  ;  they  indeed  are  almost  as  frequent  as  those  of  the 
larynx,  for  in  one  hundred  and  two  cases  in  which  the  respira- 
tory tube  was  carefully  examined,  they  existed  with  those  of 
the  larynx  and  trachea  in  the  proportion  of  eighteen,  twenty- 
two,  and  thirty-one. 

Sec.  ].  —  Ulcerations  of  the  Trachea. 

50.  When  the  mucous  membrane  of  the  trachea  was  ulcer- 
ated it  was  generally  of  a  bright  red  color.  Sometimes,  how- 
ever, and  especially  when  the  number  of  the  ulcerations  was 
inconsiderable,  it  retained  its  natural  whiteness.  This  was 
the  case  in  six  out  oC  the  thirty-one  observations  in  which  we 
have  remarked  the  alteration  alluded  to  ;  and  one  of  them  was 
an  example  of  very  extensive  ulceration  (Obs.  16).  It  was  in 
the  lower  half  of  the  trachea,  that  is,  in  that  portion  of  it 
where  ulcerations  are  the  largest  and  most  numerous,  that  the 
redness  was  most  strongly  marked.  There  were  associated 
with  it,  in  about  one  fifth  of  the  cases,  a  slight  thickening  and 
inconsiderable  softening  of  the  mucous  membrane. 

51.  When  the  ulcerations  were  small  they  were  usually 
equally  scattered  throughout  the  circumference  of  the  trachea  ; 
they  were  of  a  round  or  oval  form,  varying  from  a  line  to  a 
little  more  or  less  in  diameter.  The  mucous  membrane  was 
destroyed  by  them,  their  bottom  formed  by  the  cellular  tissue 
slightly  or  not  at  all  thickened,  their  edges  flat,  and  their  gen- 
eral appearance  that  of  having  been  made  with  an  instrument. 
It  is  now  easy  to  conceive  how  these  small  ulcerations,  with 
their  flattened  edges  and  pink  color,  should  have  escaped  no- 


44        PATHOLOGICAL  ANATOMY. TRACHEA  ;    [Part  I, 

tice,  when  the  trachea  was  not  minutely  examined  or  pre- 
viously washed. 

5*2.  If  their  dimensions  were  more  considerable,  they  were 
unequally  distributed.  The  largest  were  found  in  the  fleshy 
portion  of  the  trachea.  The  mucous  membrane  retained  in 
their  vicinity,  as  also  in  that  of  the  smaller  ulcerations,  the 
thickness,  color,  and  consistence  which  it  possessed  in  the  rest 
of  its  surface.  The  submucous  layer,  indurated  and  thick- 
ened, formed  their  lining,  or  even  this  was  either  totally  or 
partially  destroyed,  and  the  muscular  coat  exposed  in  the  cor- 
responding point  (Obs.  15,  16).  This  last  tunic,  when  thus 
denuded,  was  twice  or  three  times  as  thick  as  natural,  and 
in  a  small  number  of  cases  we  found  it  more  or  less  deeply 
ulcerated  (Obs.  16). 

A  certain  number  of  the  cartilaginous  ring-s  was  sometimes 
completely  denuded,  diminished  in  thickness,  and  either  par- 
tially destroyed,  or  their  texture  entirely  divided  at  one 
point  (Obs.  15,  16).  This  last  alteration  we  have  only  ob- 
served once  (Obs.  16)  ;  while  we  have  seen  in  five  cases 
the  complete  destruction  of  the  mucous  membrane  of  the 
trachea  throughout  almost  the  whole  extent  of  its  fleshy  por- 
tion. (Obs.  15,  43). 

53.  The  preference  which  the  large  ulcerations  almost  con- 
stantly exhibited  for  the  posterior  portion  of  the  trachea  may, 
perhaps,  find  a  solution  in  the  constant  passage  of  the  sputa, 
and  their  more  or  less  prolonged  contact  on  this  particular 
part.  For,  if  too  exciting  liquids  produce  inflammation  and 
ulceration  of  the  mucous  membrane  of  the  stomach,  we  might 
expect  the  same  effect  on  the  trachea  from  the  undoubted  irri- 
tating influence  of  the  excreted  fluid.  Besides,  it  would  be 
diflîcult  to  explain  on  any  other  grounds,  why  the  ulcerations 
of  the  epiglottis  exist,  as  we  shall  prove  farther  on  to  be  the 


Chap.  1.]  ULCERATIONS.  45 

case,  only  on  its  lower  surface,  the  one  which  is  more  or  less 
frequently  in  contact  with  the  sputa.* 

But  while  we  admit  that  the  expectorated  matter  may  have 
a  decided  influence  both  upon  the  extent  and  seat  of  the  ulcer- 
ations of  the  trachea,  we  must  recognise  also  some  other  cause  ; 
for  they  are  far  from  being  always  in  proportion  to  the  irrita- 
ting properties  of  the  expectoration,  nor  do  they  constantly 
exist  even  when  the  affection  of  the  lungs  is  considerable,  and 
the  tubercular  excavations  of  long  standing.  We  may  also 
add  that  the  bronchia,  in  which  the  expectorated  matter  circu- 
lates and  remains  a  greater  or  less  time,  are  less  frequently 
(we  have  only  found  them  seven  times),  the  seat  of  ulceration 
than  the  trachea.  It  is,  however,  possible  that  this  number  is 
underrated,  for,  with  respect  to  the  present  subject  of  inquiry, 
we  have  never  examined  the  bronchia  with  the  same  attention 
as  the  trachea. 

54.  In  one  third  part  of  the  cases  where  this  organ  was  free 
from  ulceration,  its  mucous  membrane  was  of  a  red  color,  in- 
creasing in  intensity  according  to  the  proximity  of  the  bifur- 
cation. It  was  still  more  marked  in  the  muscular  portion 
than  elsewhere,  so  that  it  pursued  the  same  course  as  the 
ulcerations,  and  no  doubt  partly  depended  on  the  contact  and 
retention  of  the  sputa  in  the  trachea. 

*M.  Broussais,  in  vol.  ii.  page  176,  of  his  Histoire  des  Phlegmasies  Chron- 
iques, has  ingeniously  anticipated  the  results  of  M.  Louis.  He  saj's,  "  La 
phlogose  désorganisatrice  de  la  membrane  trachéale  et  laryngée  se  présente 
en  troisième  ligne  (of  frequency).  Je  n'en  ai  pas  étudié  les  causes  détermi- 
nantes d'une  manière  bien  particulière  ;  mais  on  presume  assez  que  les 
particules  acres  et  fétides  qui  s'élèvent  des  foyers  purulents  doivent  en 
faciliter  efiftcacement  l'action."  —  Cowan. 


46  PATHOLOGICAL  ANATOMY. LARYNX   [Part  I, 

Sec.  2.  —  Ulcerations  of  the  Larynx. 

55.  These  were,  as  we  have  already  remarked,  a  little  less 
frequent  than  the  preceding,  seldom  unaccompanied  by  them, 
and  present  in  one  fourth  part  of  the  cases.  Twice  only  we 
have  observed  them  uncombined  with  those  of  the  trachea, 
and  in  many  instances  they  sensibly  varied  in  their  characters 
from  those_ïof  the  latter.  Seldom  superficial  or  presenting  the 
appearance  of  artificial  formation,  they  were  generally  of  a 
certain  depth,  more  or  less  irregular,  and  from  one  to  ten  lines 
broad.  Their  edges,  of  variable  consistence,  were  sometimes 
lardaceous,  of  a  greyish  or  whitish  color.  The  mucous  mem- 
brane was  pale  and  perfectly  sound  in  the  rest  of  its  extent. 

56.  The  most  frequent  seat  of  these  ulcerations  was  first 
the  junction  of  the  vocal  cords,  where  they  were  sometimes 
superficial  ;  then  the  vocal  cords  themselves,  especially  their 
posterior  part  ;  then  the  base  of  the  arytenoid  cartilages,  the 
larynx,  and  the  interior  of  the  ventricles,  which  we  have  found 
only  once  the  seat  of  small,  superficial  ulcers. 

In  some  instances  one  or  more  of  the  vocal  cords  were  com- 
pletely destroyed,  and  the  base  of  the  arytsenoid  cartilages  laid 
bare.  When  this  was  the  case  the  cartilages  themselves  were 
perfectly  healthy. 

Sec  .  3.  —  Ulcerations  of  the  Epiglottis. 

57.  We  have  remarked  them  eighteen  times,  or  in  about 
one  sixth  of  the  cases,  and  five  times  unaccompanied  by  those 
of  the  larynx  and  trachea.  This  complication,  however,  ex- 
isted in  the  other  cases,  so  that  all  the  examples  of  ulceration, 
enumerated  in  this  and  the  two  preceding  paragraphs,  have 
been  collected  from  forty-four  cases,  about  four  tenths  of 
those  whose  history  we  are  now  analysing. 


Chap.  1.]       AND  epiglottis;  ulcerations.  47 

Sometimes  superficial,  the  ulcerations  of  the  epiglottis  were 
generally  of  a  certain  depth,  not,  however,  (with  two  excep- 
tions) penetrating  the  fibro-cartilage  beneath.  The  mucous 
membrane  surrounding  those  which  were  superficial  did  not 
appear  evidently  thickened  ;  when  the  ulcerations  were  deep, 
it  was  rather  harder  and  thicker  than  in  the  natural  state,  either 
in  the  immediate  vicinity  or  in  the  intermediate  space.  It 
was  sometimes  likewise  of  a  rose  color,  and  in  many  instances 
the  layer  separating  it  from  the  fibro-cartilage  was  more  or 
less  puffy  in  its  texture. 

58.  The  ulcerations  existed,  as  we  have  already  remarked, 
almost  solely  on  the  laryngeal  surface  of  the  epiglottis,  and 
most  frequently  on  its  lower  half.  Once  only  we  encountered 
them  on  its  lingual  surface  (Obs.  12).  Their  dimensions 
were  from  one  to  two  lines,  often  larger.  In  some  cases  even 
the  mucous  membrane  of  the  epiglottis  was  destroyed  over  the 
whole  extent  of  the  inferior  surface  (Obs.  8,  14,  15.)  In 
others,  the  cartilage  was  destroyed  in  portions  of  its  circum- 
ference, giving  a  festooned  appearance  to  the  epiglottis.  This 
we  have  seen  four  times.  A  fifth  case  has  presented  an  ex- 
ample of  complete  destruction  of  the  epiglottis  (Obs.  13). 

59.  We  have  in  no  one  instance  discovered  tuberculous 
granulations  in  the  substance,  or  on  the  surface  of  the  epiglot- 
tis, larynx  or  trachea  ;  which  fact  induces  us  to  believe  that 
we  ought  to  consider  inflammation  as  the  most  frequent  cause 
of  the  ulcerations. 

Another  fact  of  importance  to  be  remarked  is,  that  these  ul- 
cerations were  twice  as  frequent  in  men  as  in  women.  Thus, 
in  an  equal  number  of  cases,  the  women  only  presented  six  ex- 
amples of  this  state  of  the  epiglottis,  seven  of  the  larynx,  and 
nine  of  the  trachea,  out  of  eighteen,  twenty-three  and  thirty- 
one  cases  ;    and  as  the  proportion  is   nearly  equal  for  the 


48  PATHOLOGICAL    ANATOMY. EPIGLOTTIS.    [Part  1, 

three  kinds  of  ulcerations,  it  is  probably  not  the  effect  of 
hazard.* 

EPIGLOTTIS,    LARYNX    AND    TRACHEA     IN    OTHER    DISEASES. 

60.  In  making  an  accurate  summary  of  the  state  of  the 
epiglottis,  larynx  and  trachea,  in  cases  terminating  fatally 
from  some  other  disease  than  phthisis  (particularly  chronic 
affections),  we  have  found  in  one  hundred  and  eighty  in- 
stances, one  example  of  ulceration  of  the  larynx,  and  two 
others  when  both  the  larynx  and  trachea  were  similarly  affect- 
ed. In  the  first  case  the  patient  had  died  of  pneum.onia, 
and  the  l«ngs  presented  no  trace  of  organic  lesion.  In  the 
last  two  they  died  of  cancer  and  softening  of  the  brain,  and 
had  tuberculous  cavities  in  the  lungs.  From  what  has  pre- 
ceded, it  follows  that  we  must  consider  the  ulcerationsof  the 
larynx,  and  especially  those  of  the  trachea  and  epiglottis,  as 
alterations  peculiar  to  phthisis. 

With  the  exception  of  three  cases  of  œdema  of  the  glottis 
(Obs.  46),  the  changes  we  have  described  are  the  only  ones 
these  organs  have  presented  to  us  in  phthisical  patients. 

*  The  whole  of  this  section  may  be  considered  as  peculiarly  valuable, 
and  contains  decidedly  the  most  and  only  accurate  account  which  we  yet 
possess  of  the  state  of  these  organs  in  phthisis.  The  comparative  analysis 
of  facts  proving  that  their  lesions  are  almost  peculiar  to  this  disease  is  very 
valuable,  and  gives  a  just  idea  of  what  is  still  frequently  described  as 
«'  laryngaeal  phthisis."  There  are  some  interesting  researches  on  this  sub- 
ject in  the  twenty-second  letter  of  the  second  book  of  Morgagni,  on  the 
causes  and  seat  of  diseases.  The  reader  must  not  forget  that  the  author's 
conclusions  are  confined  to  chronic  diseases,  and  where  syphilis  is  not  pres- 
ent. The  latter  has  a  special  action  on  these  organs,  and  in  typhus  and 
some  other  acute  affections  they  are  also  occasionally  ulcerated,  —  Cowan. 


Chap.  2.]    HEART  AND  PERICARDIUM  J  CONSISTENCE,  SlC.    49 


CHAPTER    II. 

ORGANS   OF    CIRCULATION. 
ARTICLE    I. 

HEART   AND   PERICARDIUM. 

61.  Phthisis  has  been  considered  as  one  among  the 
numerous  causes  of  aneurism  of  the  heart  ;  but  this  opinion 
does  not  appear  to  us  to  be  supported  by  facts.  In  one 
hundred  and  twelve  cases  where  death  was  caused  by  phthisis, 
we  have  only  found  three  examples  of  an  evident  increase  in 
the  size  of  the  heart.  This  increase  was  confined  to  the  left 
ventricle,  and  might  be  estimated  at  one  third  or  one  fourth  of 
the  normal  size  of  the  organ  ;  none  of  the  individuals  who 
presented  it  had  experienced  aneurismal  symptoms.*     In  the 

*  The  absence  of  symptoms  when  the  aratomical  characters  of  disease  are 
present  is  not  unfrequently  the  case  with  the  heart  ;  and  to  prevent  this 
being  brought  forward  as  an  argument  against  the  utility  of  pathological 
researches,  it  is  only  necessary  to  mention  that  the  variations  of  size  in  this 
organ,  when  corresponding  with  the  obstructed  state  of  the  functions  it  is 
destined  to  discharge,  are  rather  elements  of  health  (if  we  may  so  express 
ourselves)  than  of  disease.  Symptoms  only  appear  when  the  harmony  of 
organ  and  function  is  destroyed,  either  by  the  change  in  the  former  being 
prolonged  beyond  the  necessity  which  produced  it,  or  by  some  primitive 
aberration  in  the  organ  itself  from  its  healthy  state.  Of  course  this  remai-k 
only  applies  to  increase  or  diminution  of  natural,  and  not  of  morbid  struc- 
ture. —  Cowan. 


50  PATHOLOGICAL    ANATOMY. HEART,  &tC.    [Parti, 

great  majority  of  cases  the  heart  was  under  its  usual  dimen- 
sions, being  not  more  than  one  half  or  two  thirds  of  its  natural 
volume. 

This  last  fact  is  easily  conceivable  from  the  general  emacia- 
tion and  decrease  of  the  fluids  ;  but  we  cannot  apply  the  same 
reasoning  to  the  dilatation  of  the  cavities  of  the  heart  ;  for 
the  impeded  state  of  the  pulmonary  circulation,  to  which  it 
might  be  attributed,  is  gradually  produced,  and,  consequently, 
being  proportionate  to  the  circulating  fluid,  on  that  account  is 
not  to  be  considered  as  a  cause  of  dilatation.  Let  us  add 
that,  if  this  obstruction  was  to  cause  increase  of  the  heart's 
volume,  it  would  take  place  on  the  right  side  only,  which  is 
contrary  to  observation. 

62.  Diminution  of  the  volume  of  the  heart  was  evident  in 
the  great  majority  of  instances,  both  in  patients  whose  disease 
had  progressed  slowly,  and  in  others  where  the  fatal  termina- 
tion was  not  protracted  beyond  a  ïew  months.* 

63.  The  heart  was  in  general  of  good  consistence.  We 
have,  however,  found  it  more  or  less  flaccid  and  soft  in  about 
one  fifth  of  the  cases,  and  this  diminished  consistence  was  not 
proportionate  either  to  the  duration  of  the  disease  or  the  age 

*  M.  Broussais,  to  invalidate  the  author's  conclusion  relative  to  the  state 
of  the  heart  in  phthisis,  says  that  he  has  observed  hypertrophy  of  the  heart 
to  be  sometimes  the  cause  of  phthisis,  and  that  it  afterwards  becomes  atro- 
phied with  the  other  organs.  The  proof  of  this  would  require  numerous 
detailed  facts  j  the  mere  assertion  of  what  would  be  extremely  difficult  to 
substantiate  is  valueless.  —  (Examen,  des.  Doct.  Med.  vol.  iv.  page  338.) — 
Dr.  Clarke,  in  his  work  on  Climate,  page  318,  says,  "  In  hereditary  cases 
of  phthisis,  I  think  the  powers  of  the  heart  are  under  the  ordinary  standard. 
A  small,  feeble  heart  1  consider  a  strong  predisposing  cause  of  consumption." 
It  will  ever  be  thus  with  what  we  call  facts  in  medicine,  when  assertions 
have  no  other  basis  than  the  impressions  of  unrecorded  experience.  — 
CowAN. 


Chap.  2.]     CONSISTENCE  ;  hypertrophy,  &z;c.  51 

of  the  patient.  At  other  times  it  was  firmer  than  usual,  which 
generally  coincided  with  the  hypertrophy  of  the  parietes  of 
one  or  other  of  its  cavities. 

64.  This  thickening  was  remarkably  developed  in  seven 
cases  ;  six  times  in  the  left,  and  once  only  in  the  right  ventri- 
cle ;  inversely  to  what  would  be  the  case  were  an  obstacle  to 
the  pulmonary  circulation  the  cause  of  the  phenomenon.  In 
these  different  instances  the  cavity  of  the  heart  was  diminish- 
ed, though  the  volume  of  the  organ  had  not  sensibly  changed  ; 
it  was  sometimes  even  less  than  natural  ;  and  we  might  in 
that  case  admit  that  the  apparent  increase  of  thickness  arose 
not  from  hypertrophy,  but  from  the  contraction  of  the  parietes 
on  themselves.  We  frequently  observe  the  same  fact  in  the 
intestines  when  they  are  contracted. 

65.  Diminished  thickness  of  the  ventricles  was  less  fre- 
quent. We  have  only  observed  it  twice  on  the  right,  and 
four  times  on  the  left  side  ;  so  that,  under  whatever  point  of 
view  we  consider  the  cavities  of  the  heart,  we  find  that  those 
of  the  right  side  less  frequently  deviate  from  a  healthy  state 
than  those  of  the  left  ;  and  all  that  we  can  possibly  conclude 
respecting  the  influence  of  phthisis  on  the  heart,  is,  that  its 
volume  is  diminished  in  common  with  that  of  the  other 
organs. 

66.  In  no  instance  have  we  found  organic  alteration  in 
either  of  the  cavities  of  the  heart  ;  by  which  we  may  infer 
that  the  mere  activity  of  an  organ  is  not  sufficient  to  explain 
the  more  or  less  frequent  alterations  of  tissue  of  which  it  is 
susceptible. 

67.  We  have  twice  met  with  adhesion  of  the  pericardium  to 
the  heart.  In  a  third  instance  the  membrane  connecting  them 
was  a  line  in  thickness,  of  moderate  consistence,  and  enclosing 
in  its  substance  a  small  quantity  of  clear  fluid.     The  patient 


52  PATHOLOGICAL    ANATOMY. AORTA;         [Parti, 

who  presented  this  example  of  pericarditis  (Obs.  19),  expe- 
rienced great  palpitations,  and  her  pulse  was  extremely  irreg- 
ular during  the  twenty-three  days  she  was  submitted  to  our 
observation. 

In  a  tenth  part  of  the  cases  there  was  an  effusion  of  five  or 
six  ounces  of  serum  in  the  pericardium. 

HEART    IN    OTHER    CHRONIC    DISEASES. 

68.  At  the  termination  of  other  chronic  diseases  the  state 
of  the  heart  was  nearly  the  same  as  in  phthisis.  Out  of  eighty 
cases  we  found  it  larger  than  natural  in  five  ;  in  nine,  it  was 
flaccid  and  soft  ;  in  eight,  the  left  veijiricle  was  hypertro- 
phied  ;  and  in  seven  it  was  diminished  in  thickness,  whilst  the 
right  ventricle  presented  only  a  single  example  of  either  of  these 
deviations.  Lastly,  the  volume  of  the  heart  was  much  less 
than  natural  in  thirty  cases,  or  nearly  one  third,  a  higher  pro- 
portion than  in  phthisis.  This  difference  is  to  be  attributed  to 
the  presence  of  cancerous  affections,  especially  of  the  stomach 
and  uterus,  in  which  the  diminished  volume  of  the  heart  was 
both  more  frequent  and  more  strongly  marked  than  in  any 
other  disease  whatever. 


ARTICLE     II. 

AORTA, 

69.  In  the  majority  of  instances  it  was  healthy,  and  in  one 
fourth  of  the  cases  more  or  less  red,  either  partially,  or  over 
the  whole  of  its  extent.  This  redness  penetrated  to  a  varia- 
ble depth  in  the  middle  tunic,  occupying  the  whole  circum- 
ference of  the  vessel,  whether  it  contained  little  or  no  blood  ; 
so  that  we  could  not  consider  it  the  effect  of  imbibition.     It 


Chap.  2.]  ORGANIC    DISEASES  ;    SIZE.  53 

sometimes  extended  into  the  principal  ramifications  from  the 
aorta,  particularly  into  the  carotids.  With  one  exception  it 
was  confined  to  patients  between  the  ages  of  twenty  and 
thirty-two  (Obs.  1,  19,  30,  40,  he). 

70.  The  organic  alterations  of  the  aorta  ;  the  soft  and 
yellow,  or  white  and  cartilaginous  patches  ;  the  ulcerations  so 
frequently  resulting  from  them  ;  and  lastly,  the  osseous  de- 
posits were  rather  less  frequently  observed  than  the  redness  ; 
they  were  only  present  in  one  sixth  part  of  the  cases  only, 
either  separately  or  combined,  and  in  individuals  from  the  age 
of  thirty-five  to  seventy-five.  In  general  they  were  more  ad- 
vanced in  their  development,  and  occurred  more  frequently  at 
the  bifurcation  of  the  aorta  than  at  any  other  point. 

71.  In  consequence  of  the  diminished  quantity  of  the  circu- 
lating fluids,  it  was  natural  to  suppose  that  the  arterial  system, 
especially  the  aorta,  would  present  a  less  considerable  volume 
in  cases  fatal  from  phthisis  than  from  acute  affections.  This 
difference  was  actually  found  to  exist,  though  less  marked  than 
we  might  at  first  have  presumed.  Thus,  in  twelve  persons 
from  twenty  to  thirty  years  old,  who  died  of  typhus,  the  aorta 
had  for  mean  dimensions,  counting  respectively  from  the  parts 
corresponding  to  the  free  edge  of  the  sigmoid  valves,  from  one 
inch  below  the  origin  of  the  left  subclavian,  one  inch  above 
the  cseliac  trunk,  and  at  the  point  of  bifurcation  into  the  two 
iliacs,  twenty-eight  lines  and  nine  tenths  ;  twenty  lines  and  four 
tenths  ;  seventeen  lines  and  nine  tenths  ;  and  thirteen  lines  and 
sixth  tenths  ;  whilst  in  an  equal  number  of  phthisical  patients 
of  the  same  age  and  measured  in  a  similar  way,  it  was  in  the 
same  points  twenty-seven  hnes  and  four  tenths  ;  nineteen  lines 
and  three  tenths  ;  sixteen  lines  and  seven  tenths  ;  and  twelve 
lines  and  six  tenths  ;  a  difference,  though  certainly  slight,  yet, 
however,  real  and  proportioned  every  where  to  the  volume  of 


54  PATHOLOGICAL   ANATOMY. AORTA  ;         [Part  I, 

the  artery  ;  so  that  where  the  dimensions  were  the  smallest 
the  difference  was  less  than  it  was  any  where  else,  and  was 
precisely  one  line.* 

We  have  instituted  this  comparison  in  subjects  of  the  same 
age,  because  the  aorta  at  different  periods  of  life  varies  greatly 
in  its  dimensions.  Thus,  from  the  age  of  forty  to  fifty,  it  was 
thirty-four  to  thirty-five  lines  wide  at  the  part  corresponding  to 
the  free  edges  of  the  sigmoid  valves,  in  cases  fatal  from  acute 
diseases  ;  it  was  thirty-two  lines  wide  in  cases  of  phthisis,  and 
only  thirty  in  individuals  of  the  same  age  who  died  from  cancer  ; 
these  differences  existed  throughout  the  whole  length  of  the 
artery,  proportionately  to  its  diameter,  and  the  last  fact  merits 
particular  attention,  as  it  coincides  with  our  previous  remarks 
on  the  smallness  of  the  heart  in  cancerous  affections. 

AORTA    IN    OTHER    CHRONIC    DISEASES. 

72.  The  lesions  of  the  aorta,  which  we  have  just  enume- 
rated, were  present  after  other  chronic  diseases,  but  not  in  the 
same  proportion.  The  redness  existed  in  one  eighth  part  of 
the  cases,  and  the  organic  alterations  in  one  half.  This  differ- 
ence might  favor  the  supposition  that  there  was  some  connexion 
between  the  different  states  of  the  aorta  and  the  nature  of  the 
disease,  but  the  consideration  of  the  age  explains  all.  In 
shoit,  whether  redness  of  the  aorta  was  observed  after  phthisis 

*  The  inequality  of  the  dimensions  of  the  aorta  in  the  portion  comprised 
between  the  left  subclavian  and  the  caeliac  trunk,  proves  that  this  artery  is 
not  composed  of  a  succession  of  cylinders,  hut  that  it  is  really  cone  shaped. 
We  have  established  the  same  fact  for  the  femoral,  the  primitive  carotid, 
and  some  of  the  smaller  vessels.  —  Louis.  — A  valuable  memoir  will  ap- 
pear on  this  subject  by  M .  Bizot,  in  the  first  volume  of  Memoirs  of  the  Société 
Médicale  d'  Observation,  to  be  published  the  ensuing  winter.  —  Cowan. 


Chap.  2.]  IN    OTHEK    CHRONIC    DISEASES.  55 

or  any  other  chronic  disease,  it  was  always  in  individuals 
from  twenty  to  thirty-five  years  of  age  ;  and  we  must  recol- 
lect that  the  majority  of  phthisical  patients  die  in  the  earlier 
periods  of  life,  while  it  is  generally  at  a  more  advanced  period 
that  other  chronic  diseases  are  fatal. 

73.  The  frequency  of  organic  lesions  of  the  aorta,  contrasted 
with  the  great  rarity  of  those  of  the  heart,*  confirms  what  we 
have  previously  mentioned,  viz.  (67),  that  this  kind  of  alter- 
ation is  not  always  in  proportion  to  the  activity  of  the  func- 
tions of  an  organ  ;  for  those  of  the  aorta  are  almost  wholly 
mechanical. 

'  74.  When  the  internal  membrane  of  the  aorta  was  red,  it 
was  not  thickened  ;  but  sometimes,  in  the  points  where  this 
tint  was  deepest,  we  have  found  it  less  consistent  and  more 
easily  separated  from  the  middle  coat  than  in  a  state  of  health. 
The  latter,  even  when  colored,  offered  no  similar  alteration  ; 
and  as  redness  (usually  the  only  appreciable  change  of  the  in- 
ternal membrane),  is  not  sufiîcient  to  characterise  inflamma- 
tion, it  seems  more  prudent,  before  coming  to  a  decision,  to 
await  additional  facts.  M.  Bertin,  indeed,  in  his  work  on 
diseases  of  the  heart,  relates  a  case  in  which  he  found  the  in- 
ternal membrane  of  the  aorta  of  a  bright  red,  and  lined  by 
a  coagulated  membranous  exudation  ;  or,  in  other  terms, 
evidently  inflamed.  But  the  author  has  confined  himself  to 
the  description  of  the  redness,  and  has  omitted  to  mention  the 
consistence  or  thickness  of  the  arterial  coats  ;  so  that  his  ob- 
servation, in  other  respects  so  interesting,  cannot  sanction  any 

*  In  three  hundred  and  fifty  cases,  fatal  from  a  great  variety  of  diseases, 
we  have  only  found  two  instances  of  organic  disease  of  the  heart,  and  it  con- 
sisted each  time  of  a  partial  transformation  of  its  tissue  into  cancerous  matter. 
Loni3. 


S6         PATHOLOGICAL  ANATOMY. AORTA.     [Part  I, 

general  conclusion  as  to  when  the  redness  we  are  now  con- 
sidering may  be  regarded  as  inflammatory.* 

With  respect  to  the  yellow  or  white  and  cartilaginous  spots, 
&c.,  of  which  we  have  already  spoken,  their  origin  seems 
still  more  obscure.  We  only  meet  them  after  a  certain  period 
of  life,  (36  or  40),  and  they  are  then  more  or  less  frequent  in 
almost  every  instance.  From  this  it  appears  they  are  regu- 
lated by  primitive  laws,  common  to  all,  and  the  natural  conse- 
quence of  age.  No  symptoms  disclose  their  existence,  and  we 
do  not  see  on  what  foundation  they  can  be  regarded  as  inflam- 
matory products.  To  establish  such  a  conclusion,  it  would 
be  necessary,  we  think,  to  demonstrate  that  there  is  not,  and 
could  not  be,  any  organic  lesion  independently  of  inflammation. 

*  We  would  refer  our  readers  to  an  able  article  by  Laennec,  page  644, 
on  the  redness  of  the  lining  membrane  of  the  arteries;  to  Andral's  (Clin. 
Med.)  and  to  a  memoir  by  M.  M.  Rigot  and  Trousseau,  in  the  Archives 
Gen.  de  Med.  vol.  xii,  and  Gendrin.  Hist.  .ânat.  des  Injlam.  vol.  ii.  page 
9.  There  is  every  reason  for  supposing  the  phenomenon,  when  not  attend- 
ed by  other  changes,  to  be  the  result  of  imbibition.  The  state  of  the  blood 
at  the  moment  of  death,  the  temperature  and  the  free  or  embarrassed 
state  of  the  respiratory  functions,  seem  among  the  most  active  causes  of  the 
appearance  in  question.  By  Bouillaud,  (Die.  de  Med.  Prat.  vol.  iii.) 
Berlin,  Kreysig  and  Frank,  it  has  given  rise  to  a  theory  ofjever,  which, 
with  the  former  at  least,  is  a  kind  of  arteritis.  The  various  opinions  enter- 
tained on  this  question  affords  a  striking  illustration  of  the  pliability  ot facts, 
when  arrayed  in  support  of  some  favorite  doctrine.  M.  Louis  (Vide  Ex- 
amen, page  5,)  has  since  concluded  from  the  analysis  of  a  great  number 
of  fatal  cases  from  a  variety  of  acute  affections,  that  the  redness  of  the  aorta 
is  a  special  phenomenon  of  imbibition,  depending  on  an  alteration  of  the 
blood, —  of  the  arterial  tissue,  or  both,  in  certain  cases.  —  Cowan.  —  See 
Louis  on  Fever,  vol.  i.  page  291  to  294.  —  H.  L  B. 


Chap.  3.j  PHARYNX    AND    (ESOPHAGUS.  57 


CHAPTER    III. 

DIGESTIVE  ORGANS. 
ARTICLE    I. 

PHARYNX  AND  ŒSOPHAGUS. 

75.  They  were  almost  constantly  healthy. 

In  eighty  cases  the  only  alterations  we  have  observed  in 
the  pharynx  v/ere  ulcerations  in  two  instances.  These  were 
small,  numerous,  and  nearly  uniformly  distributed  over  the 
whole  of  the  mucous  membrane,  which  was  slightly  thickened 
in  the  intervening  portions  (Obs.  13,  29). 

76.  In  two  other  examples  we  have  found  ulcerations  in 
the  œsophagus.  In  one  of  these  but  a  single  ulceration,  five 
lines  broad  and  situated  in  the  central  part  of  the  organ,  could 
be  observed.  It  was  lined  by  an  extremely  thin  layer  of  cel- 
lular tissue,  and  round  its  edge  the  mucous  membrane  was 
thickened  and  detached  with  the  subjacent  layer  over  a  space 
of  two  lines.  In  the  other  instance,  there  were  numerous 
minute,  superficial  ulcerations,  as  if  artificially  produced 
(Obs.  34). 

77.  We  have  frequently  seen  the  internal  surface  of  the 
œsophagus  lined  by  a  kind  of  broken  up  false  membrane,  very 
much  resembling  those  apthous  exudations  so  frequent  in  the 

H 


5S  PATHOLOGICAL    ANATOMY.  PHARYNX,  &C.    [Part  I, 

interior  of  the  mouth,  and  of  which  we  shall  hereafter  speak 
(354).  Here  the  epithelium  had  disappeared  ;  but  the  mucous 
membrane  presented  no  alteration  in  color,  consistence,  or 
thickness  (Obs.  30). 

78.  The  lower  portion  of  the  oesophagus  was  in  three  cases 
softer  and  thinner  than  usual  ;  this  lesion  equally  extending  to 
all  the  membranes,  and  also  existing  in  the  stomach. 

79.  We  have  never  detected  any  symptom  which  could  be 
referred  either  to  the  ulcerations  of  the  pharynx,  to  those  of 
the  œsophagus,  or  the  diminished  thickness  of  the  lower  por- 
tion of  the  latter.  The  same  observation  may  be  made  in 
regard  to  the  soft,  pultaceous  membrane  already  mentioned, 
unless,  indeed,  it  can  be  considered  as  the  cause  of  the  dys- 
phagia which  existed  in  one  instance  for  a  considerable  time 
(Obs.  30). 

PHARYNX    AND    ŒSOPHAGUS    IN    OTHER   CHRONIC    DISEASES. 

80.  In  the  post  mortems  of  individuals  who  died  of  many 
other  chronic  affections,  there  were  neither  ulcerations  nor  thin- 
ning of  the  pharynx  or  oesophagus.  In  cases  fatal  from  acute 
diseases  we  have  never  found  ulcerations  of  the  mucous  mem- 
brane of  the  latter,  except  in  typhus  ^ever.*  The  species 
of  detritus  or  of  false  membrane,  of  which  we  have  spoken, 
was  present  more  or  less  frequently  after  all  chronic  affec- 
tions. 

*  See  Louis  on  Fever,  vol.  i.  pages  150  and  15L  — H.  I.  B. 


Chap.    3.]    STOMACH  IN  OTHER  CHRONIC  DISEASES.  59 


ARTICLE   IT, 

STOMACH, 

Sec.  1.  —  Volume  and  Situation  of  the  Stomach. 

81.  In  both  these  respects  the  changes  were  sometimes 
remarkable.  Out  of  ninety-six  observations,  when  they  were 
carefully  noted,  in  nine  the  stomach  was  twice  or  three  times 
its  natural  volume,  and  situated  lower  in  the  abdomen  than  is 
usual.  In  six  of  these  cases  its  great  curve  was  on  a  level 
with  the  iliac  crest  (Obs.  18,  19).  In  the  other  three  it  de- 
scended only  a  little  below  the  umbilicus.  In  all,  the  liver 
was  voluminous,  overlapping  more  or  less  the  anterior  surface 
of  the  stomach. 

STOMACH    IN    OTHER    CHRONIC    DISEASES, 

82.  This  considerable  displacement  and  increased  volume  of 
the  stomach,  are,  if  we  may  so  express  ourselves,  peculiar  to 
phthisis.  They  are  very  rarely  observed  in  cases  fatal  from 
other  affections,  which  may  lead  us  to  presume  that  they  are 
for  the  most  part  to  be  considered  as  the  consequence  of  re- 
peated shocks  caused  by  the  cough.*     Out  of  two  hundred 

*  The  effect  of  cough  on  the  dilatation  of  the  stomach  may  certainly  be 
questioned,  both  from  the  physical  laws  which  regulate  the  abdominal 
cavity,  and  the  fact  that  in  phthisis  the  cough  is  not  so  violent  or  so  chronic 
as  that  accompanying  some  other  thoracic  affections.  In  one  remarkable 
instance  in  the  wards  of  M.  Piorry,  at  La  Pitié,  the  stomach  descended 
nearly  to  the  pubis  (which  was  ascertained  by  percussion  and  change  of 
position  after  the  patient  had  taken  a  large  quantity  of  fluid),  and  here  there 
were  no  symptoms  of  thoracic  disease.  —  Cowav. 


60  PATHOLOGICAL    ANATOMY.  - —  SÏOMACH  ;       [Part  I, 

and  thirty  cases  of  various  chronic  and  acute  diseases  we  have 
only  seen  it  in  two  instances.  One  was  a  case  of  diseased 
heart,  —  the  other  caries  of  the  vertebrae.  In  both  the  great 
curvature  of  the  stomach  descended  as  low  as  the  superior 
iliac  spine  and  the  liver  was  also  of  large  size  and  low  down  5 
so  that  whenever  we  have  encountered  this  combination  there 
was  a  constant  relation  between  the  liver  and  stomach. 

83.  The  alterations  of  the  latter  were  principally  in  the 
mucous  membrane.  This  was  both  thinned  and  softened, 
sometimes  even  destroyed  ;  in  other  cases  it  was  more  or  less 
rddj  and  occasionally  thickened  on  its  anterior  surface  ;  while 
again  in  others  the  redness,  accompanied  by  very  marked 
softening,  existed  only  in  the  great  cul-de-sac.  Ulcerations 
were  sometimes  found  ;  but  more  frequently  there  was  a  re- 
markable mamillated*  appearance  of  the  mucous  membrane. 
We  shall  now  successively  describe  these  alterations. 

Sec.  2. —  Softening  with  diminished  thickness  of  the  Mucous  Membrane 
of  the  Stomach. 

84.  This  condition  of  the  mucous  membrane,  which  we 
have  already  described,!  was  present  in  about  one  fifth  of  the 

*  What  this  term  includes  will  be  seen  by  reference  to  paragraph  94.  — ■ 
Louis.  —  It  corresponds  to  niarneloriated  in  the  translation  of  the  work  on 
Fever.  — H.  I.  B. 

t  Vide  Louis  sur  Diverses  Maladies,  Paris,  1826.  The  memoir  referred 
to  is  founded  on  four  hundred  and  fifty  post  mortems  of  patients  in  the  warda 
of  M.  Chorael  ;  the  morbid  alteration  forming  the  subject  of  this  section  waa 
present  in  one  twelfth  of  the  cases  taken  indiscriminately.  This  result  was 
confirmed  by  subsequent  facts.  "  In  two  hundred  cases  fatal  from  chronic 
diseases,  thirty-three  presented  the  lesion  in  question;  twenty-one  were 
women,  twelve  men.  Out  of  one4iundred  and  fifteen  cases  of  acute  affec.* 
lions,  this  condition  of  tho  stomach  existed  in  twelve.     In  one  sixth  of  the 


Chap.  3.]       SOFTENED,    THINNED,    PERfORATÉDé  Gl 

cases,  or  nineteen  times  out  of  ninety-six.  It  was  most  fre- 
quently observed  in  the  upper  part,  and  especially  in  the 
great  cul-de-sac  of  the  stomach.  It  very  frequently  extended 
over  half  of  the  mucous  membrane,  or  still  farther,  while  it 
was  occasionally  bounded  to  an  extent  not  exceeding  eight  or 
ten  square  inches  (Obs.  1,  3,  4,  7,  26,  27,  32,  35,  39). 

85.  The  affected  portions  had  a  pearly  or  slightly  yellow 
aspect,  were  destitute  of  mucus,  and  remarkable  for  the 
great  number  of  large  and  usually  empty  vessels,  which  were 

chronic  cases  it  was  not  indicated  during  life  by  any  symptoms.  The  alter- 
ation was  always  more  frequent  in  women  than  in  men,  which  seems  to 
prove  that  the  influence  of  strong,  stimulating  drinks  is  not  the  most  usual  or 
energetic  cause  of  serious  lesions  of  the  gastric  mucous  membrane.  This  idea 
is  strengthened  by  the  examination  of  facts  where  corrosive  substances  have 
been  swallowed,  but  not  in  sufficient  quantity  to  cause  death.  Though  oc- 
casioning the  most  violent  symptoms,  the  functions  of  the  stomach  are  per- 
fectly re-established  after  a  few  days.  Nearly  all  the  facts  in  Orfila's  Tox' 
itology  may  be  cited  in  proof  of  this  ;  two  hundred  patients  in  the  venereal 
hospital  of  Paris,  were  poisoned  by  an  accidental  overdose  of  corrosive  sub- 
limate, of  which  the  minimum  was  ij.  to  iij.  gr.  Atrocious  epigastric  pains, 
vomitings  and  constriction  of  the  throat  followed  ;  but  all  got  well  after 
a  few  hours  by  the  use  of  emollient  albuminous  drinks.  In  ten  or  twelve 
there  were  slight  epigastric  pains  during  a  fortnight.  Not  one  was  attacked 
with  acute  or  chronic  gastritis  of  any  duration.  May  we  not  conclude  that 
the  apparent  causes  of  gastritis  are  only  secondary,  and  that  this  disease  re- 
quires a  very  marked  predisposition  F"  Are  not  the  results  of  stimulants 
on  the  stomach  often  exaggerated  ?  "  Is  there  not  a  marked  difference 
between  a  gastritis  from  an  external  and  an  internal  cause  ?"  Authors  do 
not  appear  to  have  sufficiently  insisted  upon  this  point,  and  to  our  own  mind 
it  is  at  once  a  quietus  to  many  favorite  theories  on  gastritic  inflammation,  and 
a  strong  reason  for  considering  as  merely  accidental  complications,  many 
local  changes  which  have  been  frequently  regarded  as  the  cause  of  the  gen- 
eral symptoms  instead  of  as  one  of  their  effects.  This  is,  however,  not  the 
place  for  extending  our  remarks  on  this  subject;  we  may  observe  that  in  the 
above  cases  the  results  of  M.  Louis  as  to  the  correspondence  between  the 
tongue  and  the  stomach,  mentioned  in  anotlier  part  of  this  work,  were  fully 
confirmed.  — Cowan. 


fâ  PATHOLOGICAL    ANATOMY.  STOMACH  ;       [Part  I, 

occasionally  filled  by  a  darkish  colored  blood.  They  were 
flattened,  and  the  mucous  membrane  was  more  or  less  raised 
about  their  edges.  These  peculiarities  were  obvious,  and  at 
once  indicated  the  seat  of  the  morbid  alteration  we  are  now 
considering.  In  these  points  the  mucous  membrane  was  pale, 
semi-transparent,  sometimes  greyish,  or  of  a  dull  red  color. 
It  was  extremely  softened  ;  often  not  firmer  than  moderately 
viscous  mucus.  Its  thickness  was  nearly  that  of  the  mucous 
membrane  of  the  small  intestines  ;  in  some  cases  it  was  en- 
tirely destroyed  over  a  certain  space.  In  many  cases,  near 
parts  which  were  thinned  and  softened,  there  were  others 
which  were  rather  soft  than  thin,  and  vice  versa.  A  compar- 
ative section  of  the  diseased  and  healthy  portions  proved  the 
great  relative  difference  of  thickness. 

86.  Instead  of  constantly  occupying  a  continuous  surface, 
the  alterations  we  are  considering  sometimes  assumed  the  form 
of  bands,  but  in  this  case  the  deviation  from  the  healthy  state 
was  commonly  not  so  strongly  marked.  These  bands  were 
from  two  to  three  inches  long,  of  the  same  and  sometimes  a 
greater  number  of  lines  in  breadth,  and  were  approximated  to 
each  other,  the  intermediate  mucous  membrane  retaining  its 
natural  thickness. 

87.  The  cellular  tissue  under  the  mucous  membrane,  which 
was  diseased,  was  usually  sound.  In  four  instances  only  it 
was  completely  softened,  yielding  to  the  slightest  force,  and 
both  the  muscular  and  peritoneal  coats  were  similarly  affected 
in  the  corresponding  points.  Thus,  we  have  frequently  found 
the  stomach  perforated,  notwithstanding  our  employing  the 
greatest  precaution  when  detaching  it  from  the  neighboring 
parts  ;  while  the  absence  of  all  effusion  into  the  peritoneum 
proved  that  the  perforation  could  not  have  existed  during  life 
(Obs.  7,  32). 


Chap.  3.]  MAMILLATED.  63 

88.  In  the  majority  of  instances  the  mucous  membrane  ad- 
joining the  softened  part  was  mamillated,  of  a  red  or  greyish 
color,  over  a  considerable  extent  (Obs.  1,  4,  35),  occasionally 
thickened  or  ulcerated  ;  and  sometimes,  though  very  rarely, 
the  thinned  and  softened  portion  was  continuous  with  another 
equally  thin,  but  of  a  bright  red  color,  and  becoming  gradually 
thicker  (Obs.  39). 

89.  When  there  were  redness,  thickening,  and  sometimes 
softening  of  the  mucous  membrane,  the  existence  of  inflam- 
mation was  evident.  The  mamillated  state,  united  to  a  grey- 
ish color  and  ulcerations,  indicated,  as  we  shall  hereafter  see 
(94),  a  similar  lesion,  so  that  in  more  than  one  half  of  the 
cases,  the  thinned,  softened,  and  pale  mucous  membrane  was 
continuous  with  a  part  evidently  inflamed.  From  this  it  is 
natural  to  suppose  that  softening  and  diminished  consistence 
are  among  the  effects  of  inflammation  ;  and  what  renders  this 
conclusion  still  more  probable  is,  that  when  these  were  alone 
present,  the  symptoms  observed  were  those  of  gastritis.  Di- 
minished thickness  and  paleness  of  the  mucous  membrane  are 
not  opposed  to  the  idea  of  inflammation,  for  we  daily  see,  after 
the  application  of  a  blister,  and  frequently  but  for  a  short 
time  only,  the  skin  become  thin  and  completely  destroyed, 
and  we  might  expect  paleness  to  accompany  approaching  de- 
struction.* We  have  more  frequently  remarked  this  state  of 
the  stomach  in  women  than  in  men  (in  the  proportion  of 
twelve  to  seven),  which  seems  to  indicate  that  the  most  cora- 

*  It  is  rather  amusing  to  find  M.  Broussais  admitting  that  in  this  section 
the  author  is  "  de  bonne  foi,"  because  he  does  not  hesitate  to  explain  these 
organic  lesions  by  inflammation  :  that  is,  whenever  he  agrees  with  M. 
Broussais,  he  is  right,  when  he  differs,  he  is  wrong.  This  is,  throughout, 
the  spirit  of  M.  Broussais's  strictures.  —  Vide  Examen,  vol.  iv.  page  339.  — 
Cowan. 


64  PATHOLOGICAL    ANATOMY.  STOMACH  ;       [Part  I, 

mon  exciting  causes  are  not  excesses  in  eating,   women  being 
less  addicted  to  them  than  men.* 

Sec.  3.  — Redness  combined  with  thickening,  with  a  mamillated  state  or 
softening  of  the  Mucous  Membrane,  and  occurring  in  the  anterior 
portion  of  the  Stomach. 

90.  In  eight  cases  out  of  ninety-six  we  have  found  this 
species  of  alteration.  The  mucous  membrane  was  sometimes 
smooth,  sometimes  uneven  and  mamillated  (mamelonnée), 
and  almost  constantly  covered  by  a  very  copious  and  tenacious 
mucus,  which  was  here  always  more  viscous  and  abun- 
dant than  in  any  other  part.  In  some  instances,  the  con- 
sistence of  the  mucous  membrane  was  diminished  and  its 
thickness  greater  than  natural.  In  one  of  these,  the  red  and 
thickened  part  was  lined  by  a  soft,  yellowish  false  membrane, 
not  extending  beyond  the  part  affected.  This  modification, 
evidently  inflammatory,  existed  in  individuals  of  different  ages, 
and  the  duration  of  whose  disease  had  varied  from  three  to 
five  years  ;  it  was  also  much  more  frequent  in  women  than  in 
men,  in  the  proportion  of  seven  to  one  (Obs.  10,  18,  29). 
In  the  rest  of  its  extent  the  mucous  membrane  approximated 
more  or  less  closely  to  a  healthy  state. 

91.  The  situation  and  volume  of  the  stomach  had  under- 
gone some  remarkable  changes  ;    its  dimensions  were   very 

*  The  author's  subsequent  experience  as  to  the  softened  and  thinned  state 
of  the  gastric  mucous  membrane,  (Vide  Affect.  TypliOide,  vol  i.  page  183, 
Paris  edition,  and  Translation,  page  161,  and  A-ppendix),  incHnes  still  more 
to  the  belief,  that  in  some  instances  it  is  not  depending  on  inflammation  ; 
this  supposition  is  founded  upon  the  facts,  that  around  tlie  softened  parts 
there  are  no  traces  of  innammalion,  and  the  submucous  layer  is  equally 
softened  and  destitute  of  all  inflainrnatory  appearances.  He  thinks,  after  the 
researches  of  Dr.  Carswcll  on  this  subject,  that  it  is  doubtful  how  far  chemi- 
cal changes  may  take  place  in  this  membrane  during  life.  —  Cov/an. 


Chap.  3.]  REDNESS    WITH    SOFTENING. 


65 


considerable,  extending  in  four  cases  to  the  iliac  crest,  while 
in  others  it  was  enlarged  in  size  without  so  marked  a  change  of 
situation.  In  all,  it  was  covered  to  a  considerable  extent  by  the 
liver,  which  was  either  larger  than  natural  or  else  descending 
below  its  usual  limits  ;  so  that  we  must  almost  necessarily  ad- 
mit that  the  liver  exercises  a  certain  influence  over  the  inflam- 
mation of  the  mucous  membrane  of  the  stomach  when  limited 
to  its  anterior  surface.*  Having  once  admitted  this  influence, 
it  would  be  easy  to  understand  why  women,  who  are  subject 
to  enlargement  of  the  liver  so  much  more  frequently  than 
men,  should  be  proportionably  liable  to  this  particular  form  of 
inflammation. 

When  we  come  to  the  description  of  the  symptoms,  we 
shall  find  that  in  many  patients  the  origin  of  the  affection 
might  be  dated  one,  two,  or  even  three  months  before  death  ; 
that  is,  at  a  period  less  remote  than  in  the  previous  case 
(328). 

Sec,  4.  —  Redness  with  softening  of  the   Mucous  Membrane  lining  the 
great  Cul-de-sac  of  the  Stomach. 

92.  This  alteration  was  present  in  seventeen  out  of  the  nine- 
ty-six cases  we  are  analysing.  The  mucous  membrane  affected 
by  it  was  usually  of  a  dull  red  color,  sometimes  a  little  thicken- 
ed, and  so  soft  that  it  would  not  bear  removal  in  strips  of  even 
the  smallest  dimensions  (Obs.  14,  15,  19).  Though  rarely 
confined  to  the  neighborhood  of  the  cardiac  orifice,  the  softening 
generally  extended  either  over  the  whole  or  a  considerable 

*  This  conclusion  of  our  author  is  the  reverse  of  M.  Broussais's.     Let  the 
reader  impartially  compare  the  state  of  the  mucous  membranes  and  that  of 
the  glands  attached  to  them,  and  he  must  admit  that  the  axioms  of  this 
pathologist  are  far  from  being  proved.  —  Cowan. 
I 


66  PATHOLOGICAL    ANATOMY.  STOMACH  ;       [Part  I, 

part  of  the  great  cul-de-sac.  The  remainder  of  the  membrane 
was  either  healthy,  or  with  an  uneven,  mamillated  appearance 
and  of  a  greyish  or  pink  color.  There  were  occasionally 
small  ulcerations  on  it. 

93.  This  morbid  condition  of  the  stomach  was  very  rarely 
accompanied  by  characteristic  symptoms,  but  it  was  of  too 
definite  a  character  to  admit  of  any  doubt  as  to  its  nature. 
For  intense  redness  combined  with  softening  and  sometimes  in- 
creased thickness,  could  only  be  the  result  of  inflammation  ; 
and  the  absence  of  symptoms  in  the  majority  of  instances 
would  favor  the  idea  that  this  inflammation  was  developed 
towards  the  close  of  life,  as  it  is  often  the  case  with  that  of  the 
pulmonary  parenchyma  and  pleurae.  Doubtless,  and  we  shall 
have  occasion  to  repeat  the  remark,  weakness  does  not  pre- 
vent the  manifestation  of  the  majority  of  the  pathognomonic 
symptoms,  but  it  sometimes  modifies  their  expression  and  de- 
creases their  number.*  Thus  the  pain  which  accompanies 
softening  and  diminished  thickness  of  the  mucous  membrane 
of  the  stomach  sometimes  disappears  several  days  before 
death  ;  also  pneumonia  occurring  in  the  last  periods  of  phthisis 
is  seldom  accompanied  by  the  yellow,  rust-colored,  viscous, 
semi-transparent  expectoration  ;    and   frequently  it  is   quite 

*  The  author  might  here  have  remarked  that  weakness  was  only  one  of 
the  causes  by  which  the  absence  or  imperfect  manifestation  of  symptoms 
might  be  explained, —  the  presence  of  another  disease  is  an  important  con- 
sideration, especially  in  those  cases  where  its  irradiated  influence  through 
the  system  causes  extensive  disturbance  of  all  the  functions.  The  instances 
are  numerous  where  fatal  disorganization  has  taken  place  almost  unknown 
and  unsuspected,  while  all  the  prominent  symptoms  have  directed  the  atten- 
tion to  some  other  affection.  Cerebral  and  enteritic  diseases  may  be  cited 
as  examples.  The  absence  of  symptoms  in  this  particular  condition  of  the 
stomach  depends  no  doubt  in  a  great  measure  on  the  anterior  surface  being 
alone  affected.  —  Cowan. 


Chap.  3.]    MAMILLATED    STATE    OF    MUCOUS    MEMBRANE.     67 

latent.  We  might  make  the  same  remark  in  regard  to  pleu- 
risy. Now  what  takes  place  in  inflammation  of  the  substance 
of  the  lung  and  pleurae  may  and  would  naturally  happen  in 
that  of  the  mucous  membrane  of  the  stomach  ;  an  additional 
motive  for  considering  the  morbid  alteration  we  have  been  de- 
scribing as  resulting  from  an  inflammation  developed  but  a 
short  time  before  death.  Surely  no  one  will  look  upon  this 
redness  and  softening  as  a  mere  post  mortem  phenomenon  ; 
for  the  stagnation  of  blood  does  not  produce  softening  of 
our  tissues,  and  we  cannot  suppose  an  identical  morbid  change 
to  arise  from  two  causes  so  wholly  different  from  each  other,* 

Sec  .  5,  —  The   mamillated  appearance  and   greyish  color  of  the  Mucous 
Membrane  of  the  Stomach. 

94.  We  have  observed  this  appearance  eighteen  times,  un- 
accompanied by  the  alterations  we  have  just  described  ;  the 
mucous  membrane,  instead  of  its  natural,  uniform  and  velvet- 
like surface,  presented  prominences  of  different  forms  and 
dimensions,  generally  rounded,  from  one  to  two  lines  in  diam- 
eter, resembling  the  fleshy  granulations  of  wounds,  and  occa- 
sionally separated  by  deep  fissures  of  variable  length,  and  a 
line  or  rather  less  in  breadth.  It  was  almost  always  of  a  grey- 
ish color,  which  was  frequently  mingled  with  a  pale  red  tint. 
In  some  instances  we  have  found  it  firmer  and  thicker  than 
natural.  It  sometimes  presented  a  few  small  ulcerations, 
which  did  not  always  involve  complete  destruction  of  the 
membrane. 

*  We  have  already  expressed  our  opinion  on  the  force  of  this  reasoning. 
Softening  may  undoubtedly  take  place  under  both  these  conditions.  — 
Cowan.  —  Softening  undoubtedly  sometimes  comes  on  after  death,  but 
then  it  is  not  caused  by  stagnation  of  the  blood,  but  by  the  gastric  juice. 
And  I  doubt  whether  even  Carswell  thinks  that  redness  with  softening 
comes  on  after  death.  —  H.  I.  B. 


68  PATHOLOGICAL    ANATOMY. STOMACH  ;        [Part  I, 

95.  This  mamillated  aspect  existed  in  very  opposite  con- 
ditions whether  the  stomach  was  contracted  or  not.  On  this 
account  it  could  not  be  attributed  to  mechanical  causes,  and 
recollecting  the  diminished  thickness  of  the  membrane  forming 
the  furrows  of  which  we  have  spoken,  its  ulcerations,  its  oc- 
casional partial  thickening  and  almost  constantly  altered  color, 
we  cannot  but  consider  it  as  a  pathological  effect.  A  similar 
state  of  things,  to  which  we  may  also  add  the  mamillated  ap- 
pearance, existing  in  cases  where  there  is  evident  inflammation 
of  the  mucous  membrane  of  the  stomach,  (as  for  instance 
when  the  anterior  surface  is  alone  affected)  seems  to  indicate 
the  inflammatory  origin  of  the  alteration  we  are  describing  ; 
and,  doubtless,  judging  from  the  absence  or  indistinctness  of  the 
symptoms  (339)  and  from  the  greyish  color  of  the  membrane 
so  frequent  in  chronic  inflammation  and  round  intestinal  ulcer- 
ations, we  may  conclude  its  progress  to  have  been  slow. 

Sec.  6.  —  Ulcerations  of  the  Mucous  Membrane  of  the  Stomach. 

96.  We  have  remarked  them  in  a  twelfth  part  of  the  cases  ; 
they  were  generally  small,  few  in  number,  and  accompanied 
with  some  other  morbid  state  of  the  raucous  membrane  ;  twice 
only  there  was  absence  of  all  complication.  In  one  of  these  a 
siniile  ulceration  existed  of  two  inches  and  a  half  of  surface 
(Obs.  38).  In  the  other  the  ulcerations  were  small,  but 
eighty  in  number  (Obs.  20).  In  all,  with  one  exception,  the 
mucous  membrane  retained  immediately  around  the  ulcera- 
tions the  same  thickness,  consistence  and  color  which  it  pre- 
sented elsewhere,  so  that  they  gave  the  impression  of  artificial 
formation.  The  exception  mentioned,  occurred  in  an  indi- 
vidual who  had,  near  the  pylorus,  an  ulceration  with  everted 


Chap.  3.J  ULCEBATioNS  ;  other  morbid  changes.         69 

edges,  formed  by  the  red,  soft,  and  thickened  mucous  mem- 
brane, the  subjacent  layers  beuig  sound. 

The  submucous  tissue,  which  formed  the  bottom  of  the 
ulcerations,  was  occasionally  thickened  ;  but  it  was  only  in  the 
instance  where  one  large  ulceration  existed,  that  it  was  par- 
tially destroyed. 

When  the  ulcerations  were  unaccompanied  by  any  other 
morbid  change  of  the  mucous  membrane,  we  may  conclude, 
from  the  history  of  the  symptoms,  that  they  dated  from  a 
period  considerably  anterior  to  the  death  of  the  patient  (336). 

Sec.  7.  —  Some  other  Morbid  Changes  of  the  Gastric  Mucous  Membrane. 

97.  In  six  cases,  where  there  was  no  alteration  of  consist- 
ence or  thickness,  it  was  more  or  less  red  throughout  its  whole 
extent.  This  redness  disappeared  after  two  or  three  hours  of 
maceration.  In  many  instances,  symptoms  of  gastritis  came 
on  two  or  three  days  before  death  (Obs.  2)  ;  rendering  it  pro- 
bable that  this  state  of  the  membrane  was  produced  by  recent 
and  slight  inflammation. 

98.  We  have  four  times  seen  the  mucous  membrane  ex- 
tremely softened  in  the  greater  part  of  the  superior  extremity 
of  the  stomach,  without  any  alteration  of  color  and  consistence, 
or  any  evident  symptoms  of  gastritis. 

99.  In  one  patient  who  died  on  the  day  of  his  arrival  at 
the  hospital,  the  mucous  membrane  presented  seven  large 
elevations,  nearly  equally  dispersed  over  its  surface,  from  two 
to  three  lines  wide  and  two  lines  high.  Adjoining  them  the 
membrane  was  slightly  red,  of  good  consistence,  and  about 
one  line  thick.  One  inch  below  the  cardiac  orifice  the  mem- 
brane was  slightly  prominent  and  raised  for  about  an  inch  in 
extent  by  a  bluish  white  fluid,  rather  viscous,  very  imperfectly 


70  PATHOLOGICAL   ANATOMY. STOMACH  ;       [Part  1, 

soluble  in  water,  and  contained  in  a  number  of  small  cells  de- 
veloped in  the  submucous  tissue. 

100.  Lastly,  of  two  phthisical  patients,  we  have  found  in 
one  a  kind  of  cicatrization  of  the  mucous  membrane  of  the 
stomach  ;  in  the  other,  the  transformation  of  a  small  portion 
of  the  muscular  tunic  into  a  cartilaginous  structure  ;  a  very 
rare  alteration,  and  which  we  shall  carefully  describe  when 
treating  of  the  symptoms  (Obs.  21,  22). 

On  summing  up  what  has  preceded,  we  have  found  in 
ninety-six  cases,  where  we  have  attentively  examined  and  de- 
scribed the  mucous  membrane  of  the  stomach,  that  it  was 

Thinned  and  softened,        .         .         .         .19  times. 

Red  and  occasionally  thickened,  mamillated  or 

softened  on  its  anterior  surface,         .          .       8     " 
Softened,  and  of  a  dull  red  color  in  the  great 

cul-de-sac,  .         .         .         .         .     17     " 

Mamillated,  of  a  greyish  color,  sometimes  red- 
dish, thickened,  Stc,       .         .         .         .     19     " 

Ulcerated,  without  other  morbid  change,       .       2     " 
Softened,  but  of  natural  color  and  consistence,      4     " 
Of  a  variably  intense  red  color  throughout  its 
whole   surface,  with  normal  thickness  and 
consistence,     .         .         .         .         .         .     6     " 

Raised  up  by  a  viscous  fluid,  &,c.,  .         .     1     " 

Apparently  cicatrized,  .         .         .         .     1     " 

Total,  77 

This  result  is  equivalent  to  saying  that  the  mucous  mem- 
brane was  only  in  a  state  approaching  to  perfect  health,  nine- 
teen times  ;  or  in  a  fifth  part  of  the  cases.* 

■*  Ândral  says  in  two  fifths.  —  Cowan. 


Chap.  3.]  IN    OTHER    CHRONIC    DISEASES.  71 

IN    PATIENTS    WHO     DIED    OF     OTHER    CHRONIC    DISEASES. 

101.  The  morbid  changes  we  have  just  described  are  not 
peculiar  to  phthisis  ;  we  have  seen  them  resulting  from  other 
chronic  diseases,  but  in  different  proportion.  In  ninety-four 
individuals  who  died  from  various  chronic  affections,  the  mu- 
cous membrane  of  the  stomach  was 

Thinned  and  softened,      ....         6  times, 

Red,  and  with  slightly  marked  inequalities  on 

its  anterior  surface,  .  .         .         .       2     " 

Softened,  and  of  a  dull  brown  in  the  great  cul- 
de-sac,  .         .         .         .         .         .       6     " 

Variably  red  over  its  whole  extent,  but  not 

softened, 18     " 

Mamillated,   greyish,  sometimes  thickened  or 

ulcerated,      .         .         .         .         .         .     16     " 

Total, 48 

That  is,  it  was  more  or  less  affected  in  one  half,  whilst 
in  phthisis  this  took  place  in  four  fifths.  It  may  also  be  no- 
ticed, that  while  in  phthisical  patients  the  most  considerable 
morbid  change,  viz.,  softening,  with  diminished  consistence, 
and  sometimes  destruction  of  the  mucous  membrane,  was 
one  of  the  most  frequent,  the  contrary  was  the  case  in  those 
who  died  from  other  diseases  ;  so  that  it  follows,  from  this 
comparison  of  facts,  that  phthisis  is  a  predisposing  cause  to 
inflammation  of  the  mucous  membrane  of  the  stomach,  and 
that  in  its  most  intense  forms. 


72  PATHOLOGICAL    ANATOMY.  DUODENUM.        [Part  1, 


ARTICLE     III, 


DUODENUM. 


102.  It  seldom  deviated  from  a  state  of  health.  Its  mu- 
cous membrane  was  sometimes  of  a  rose  color  ;  it  occasionally- 
presented  a  greyish  tint,  owing  to  an  infinitude  of  small,  black 
points,  thickly  dispersed  over  its  surface.  The  mucous  fol- 
licles were  frequently  very  apparent,  doubled  or  tripled  in 
volume,  but  not  altered  in  their  structure.  In  three  cases  out 
of  sixty,  ulcerations  were  present.  They  were  from  a  line  to 
a  line  and  half  in  breadth,  and  in  two  of  the  cases  of  a  pale 
color,  and  from  three  to  ten  in  number  (Obs.  9).  In  the 
third  instance,  some  of  them  were  from  two  to  four  lines  wide  ; 
their  bottom  blackish,  and  formed,  as  in  the  preceding  cases, 
by  the  slightly  thickened  submucous  cellular  tissue.  The 
mucous  membrane  around  them  presented  nothing  worth 
noticing. 

In  both  cases,  where  the  ulcerations  were  very  small,  there 
were  some  not  less  minute  cysts  in  the  liver,  containing  a 
greenish  and  pulpy  substance  ;  but  no  connexion  could  be 
traced  between  the  grey  and  pink  color  of  the  duodenal  mu- 
cous membrane,  the  enlargement  of  the  mucous  follicles,  and 
the  fatty  degeneration  of  the  liver.* 

*  This  result  of  our  author's  observations  calls  forth  the  ire  of  M.  Brous- 
sais,  who  suddenly  ceases  liis  commendations  of  M.  Louis's  accuracy,  by 
calling  in  question  his  veracity.  —  (Examen,  page  341).  Leaving,  how- 
ever, M.  Broussais,  we  would  remark,  that  the  relative  state  of  the  liver 
and  duodenum  ought  not  to  be  overlooked,  Laennec  says,  (page  288),  "  I 
have  seen  but  a  few  well  marked  instances  of  inflammation  of  this  intestine  ; 
I  have  frequently  found  the  duodenum  very  red  when  the  liver  was  sound, 


Chap.  3.]    SMALL  INTESTINE  ;    ITS  HEALTHY  STRUCTURE.    73 

Once  only  have  we  found  a  fibrous  tumor  similar  to  those 
of  the  uterus,  and  of  the  size  of  a  hazel-nut,  in  the  muscular 
coat  of  the  duodenum. 

IN    PATIENTS     WHO    DIED    OF    OTHER    CHRONIC    DISEASES. 

Examined  after  other  chronic  affections,  the  condition  of 
this  intestine  was  nearly  the  same  as  after  phthisis  ;  out  of 
sixty-five  cases,  we  have  observed  but  one  of  ulceration. 


ARTICLE    IV. 


SMALL  INTESTINE.* 


103.  Before  describing  the  different  lesions  of  the  small 
intestine,  we  think  it  useful  to  fix  the  attention  for  a  moment 
on  its  mucous  membrane,  and  to  point  out  a  peculiarity  of 
structure  generally  overlooked,  but  which  is  always  present  in 
a  state  of  health. 

and  the  fatty  disorganization  of  the  latter  present,  when  the  duodenum  was 
pale."  We  are,  however,  quite  aware  that  this  evidence  will  avail  little 
with  certain  individuals,  who  say  that  if  we  cannot  discover  inflammation 
(where  it  ought  to  have  existed,  according  to  their  laws),  that  it  was  there, 
but  has  disappeared.  Matter  of  fact  people  do  not  pretend  to  such  divina- 
tion. —  Cowan, 

*  There  is  a  close  analogy  between  many  of  the  remarks  made  in  this 
article  and  those  of  M.  Billard,  in  his  work  On  the  Gastro-intestinal  Mu- 
cous Membrane.  Without  attaching  undue  importance  to  this  portion  of 
our  undertaking,  which  is,  in  part,  a  mere  confirmation  of  what  is  already 
known,  we  will  mention  that  our  results  had  been  submitted  to  M.  Chomel 
several  months  previous  to  the  publication  of  the  above  work  ;  and  instead 
of  compressing  part  of  our  remarks,  we  have  purposely  left  them  unaltered, 
as  an  additional  proof  that  accurate  observation  necessarily  leads  to  the  same 
results. —  Louis. 


74     PATHOLOGICAL    ANATOMY,  SMALL  INTESTINE  ;    [Part  I, 

Sec.  1.  —  Of  the   Mucous  Membrane  of  the  Small  Intestine  in  its  healthy- 
state. 

104.  In  this  condition  the  parietes  of  this  intestine  are  very 
thin,  semi-transparent  :  allowing  us,  when  suspending  them 
over  the  extremities  of  the  fingers,  to  detect  the  small  ine- 
qualities on  the  skin. 

However,  in  this  inconsiderable  thickness  are  comprised 
the  mucous,  muscular  and  peritoneal  coats,  united  by  a  small 
quantity  of  cellular  tissue.  Whenever  either  of  these  layers 
is  in  any  way  altered,  the  semi-transparency  disappears. 

The  mucous  membrane  is  naturally  rather  thicker  in  the 
jejunum  than  in  the  ileum,  where  it  may  be  compared  in  this 
respect  to  a  sheet  of  blotting  paper. 

105.  If  we  slightly  detach  it  with  the  scalpel,  after  making 
an  incision,*  and  then  seize  it  with  the  extremity  of  the  fingers 
or  forceps,  we  can  tear  off  fragments  from  five  to  ten  lines 
long.  This  experiment  is  sufficient  to  indicate  the  natural 
firmness  of  the  mucous  membrane  ;  and  whenever  similar 
fragments  cannot  be  obtained  with  the  same  precautions,  we 
may  consider  it  as  deviating  more  or  less  from  the  healthy 
state. 

106.  The  uniform  structure  of  this  membrane  is  interrupted 
at  unequal  distances,  by  oval  patches  of  very  variable  dimen- 
sions. They  may  be  observed  in  the  three  lower  fourths,  and 
sometimes  throughout  the  w'hole  of  the  intestine.  From 
twenty  to  thirty,  and  occasionally  more,  may  be  counted. 
Situated  on  the  side  of  the  intestine,  opposite  to  tl)e  mesen- 
tery, they  are  from  one   to  four  inches  in  length,  by  eight  or 

*This  mode  of  raising  a  strip  of  mucous  membrane  is  very  faulty,  and  not 
pursued  by  Louis  at  present.  See  Appendix  to  Translation  of  Fièvre  Ty- 
phoïde, vol.  i.  page  389.  —  H.  I.  B. 


Chap.   3.]  ITS    HEALTHY    STRUCTURE.  75 

ten  lines  wide,  gradually  increasing  in  number  and  size  as 
they  approach  the  céecum  ;  they  are  very  slightly  elevated, 
though  sensible  both  to  the  sight  and  touch,  and  have  two, 
three,  or  four  times  the  thickness  of  the  surrounding  mucous 
membrane.  They  are  completely  opaque,  of  a  white  or 
greyish  color,  and  are  sometimes  studded  with  small  blue  points. 
They  do  not  offer  the  villous  surface  of  the  rest  of  the  intes- 
tine, but  present  a  great  number  of  white  or  yellowish  granu- 
lations, smaller  than  millet-seeds.  After  detaching  these 
glandular  patches  v/ith  the  precautions  already  described,  the 
granulations  are  equally  visible  on  their  adherent  surface  ;  and 
on  regarding  them  between  the  light  and  the  eye,  their  inter- 
stices appear  thin  and  semi-transparent,  very  similar  to  the 
other  portions  of  the  mucous<^membrane. 

107.  This  structure,  which  is  not  always  easily  demonstra- 
ble, in  certain  pathological  states  of  the  membrane  becomes 
most  distinct  ;  as,  for  instance,  when  it  assumes  a  deep  red 
color,  in  consequence  of  an  affection  of  the  heart.  Then,  in- 
deed, the  granulated  looking  bodies  already  described  retain 
their  naturally  white  and  yellowish  color,  and,  contrasted  with 
the  red  and  injected  state  of  their  interstices,  are  most  dis- 
tinctly visible  :  then  the  patches  assume  their  true  appearance, 
viz.,  that  of  a  collection  of  small  bodies,  no  doubt  glandular, 
in  the  substance  of  the  mucous  membrane. 

108.  The  blue-colored  spots  so  frequently  observed  upon  the 
patches  are  the  orifices  of  the  glandular  granulations.  At  least, 
judging  from  what  takes  place  in  certain  pathological  casf^s, 
this  appears  highly  probable,  for  when  these  bodies  are  greatly 
developed,  the  blue  points  are  replaced  by  distinct  openings, 
nearly  equalling  in  size  the  natural  volume  of  the  gland  itself. 

109.  The  general  appearance  of  these  patches  is  subject  to 
variation,  from  differences  in  the  arrangement  of  the  crypts. 


76       PATHOLOGICAL  ANATOMY.  SMALL  INTESTINE  ;    [Part  I, 

If  these  are  confluent,  the  interstices  on  which  their  distinct- 
ness depended  become  obUterated  ;  but  the  patches  are  not, 
on  this  account,  less  easily  recognised,  their  color,  opacity 
and  elevation  distinguishing  them  from  the  surrounding  mucous 
membrane. 

110.  They  differ  also  in  the  ileum  and  jejunum,  where 
they  interrupt  the  valvulae  conniventes,  and  have  themselves  a 
depressed  appearance,  from  the  contrasted  elevation  of  the 
valves  ;  they  have  an  areolated  surface,  and  present  nearly  the 
aspect  of  a  piece  of  lace  which  has  been  mended.  But  since 
in  the  ileum  they  are  white  or  greyish,  opaque,  and  less  inter- 
rupted by  the  valves,  they  are,  on  the  whole,  more  easily 
distinguished  in  the  upper  than  the  lower  portion  of  the  intes- 
tine. The  areolated  structure  mentioned  above  is  rarely  ob- 
served in  the  ileum. 

111.  The  whitish-colored,  isolated  granulations,  almost  con- 
stantly seen  near  the  termination  of  the  ileum,  underneath  the 
mucous  membrane,  are  liable  to  the  same  morbid  changes 
as  the  patches,  depending  upon  similar  circumstances  for  their 
greater  or  less  distinctness  ;  their  glandular  nature  is  equally 
probable. 

1 12.  Although  the  dimensions  of  the  patches  increase  as 
they  approach  the  cœcum,  it  is  not  uncommon  to  find  smaller 
ones  interspersed  with  the  larger.  Their  form,  when  this  is 
the  case,  is  more  circular  than  oval.  Near  the  caecum  they 
are  very  numerous,  and  frequently  occupy  the  whole  circum- 
ference of  the  intestine. 

113.  They  are  only  partially  affected  by  the  pathological 
State  of  the  mucous  membrane  which  surrounds  them.*     We 

*  At  this  assertion  of  what  facts  have  denionstrated,  M.  Broussais  makes 
the  following  energetic  appeal  in  behalf  of  his  infringed  laws.    "  It  is  im- 


Chap.  3.]  ITS    HEALTHY    STRUCTURE.  77 

have  already  remarked,  that  where  it  was  intensely  red  in 
consequence  of  disease  of  the  heart,  the  color  of  the  glands 
was  natural.  When  it  was  thickened,  no  change  took  place 
in  the  dimensions  of  the  patches,  and  their  elevated  appear- 
ance had  either  diminished  or  disappeared.  In  certain  cases, 
as  in  typhus  fever,  for  example,  in  which  the  mucous  mem- 
brane was  frequently  healthy,  that  covering  the  patches  was 
greatly  thickened  ;  the  glands  were  enlarged  and  the  orifices 
open.  At  first  their  structure  was  rendered  more  distinct  ; 
the}'-  soon,  however,  gradually  softened,  and  while  the  sub- 
jacent cellular  tissue  daily  increased  in  thickness,  they  ulcer- 
ated, and  were  at  last  completely  destroyed.  We  can  now 
understand  why  the  ulcerations  in  typhus  fever  are  oval  or 
elliptical  in  their  form  ;  why  they  are  found  in  the  part  of  the 
intestine  opposite  to  the  mesentery,  and  why  they  almost  in- 
variably exist  in  the  lower  portion  of  the  ileum.  These 
patches  are  also  most  frequently  the  seat  of  ulcerations  in 
phthisis.*  They  are  often  exclusively  so,  the  mucous  mem- 
brane around  them  remaining  perfectly  healthy.     Lastly,  it  is 

possible  not  to  despise  the  author's  (M.  Louis's)  prejudice  (prevention), 
since  it  has  been  verified  by  many,  and  also  by  ourselves,  during  twenty- 
seven  years,  that  the  inflammation  of  the  mucous  membrane  of  the  small 
intestine  includes  the  inflammatory  turgescence,  alteration  and  disorganiza- 
tion of  the  follicles  !"  (Examen.  Jifed.  page  341).  It  is  most  unfortunate 
iYi&t  facts  thus  foster  error.  But  they  are  indeed  "  stubborn  things  ;"  and, 
for  ourselves,  we  confess  that  three  years  and  a  half  of  unbiassed  and  re- 
corded observation  have  more  value  than  twenty-seven  years  under  oppo- 
site circumstances.  — Cowan. 

*  The  ulcerations  of  the  agminated  glands,  in  cases  of  continued  fever 
and  phthisis,  may,  we  think,  almost  decide  the  question,  whether  they 
are  mere  consequences  or  causes  of  the  peculiar  symptoms  of  the  former  ?  — 
Cowan. 


78      PATHOLOGICAL  ANATOMY.  SMALL  INTESTINE  ;    [Part  I, 

in  their  centre  that  the  perforations  of  the  small  intestines  in 
acute  diseases  take  place.* 

Sec.  2.  —  Pathology  of  the  Small  Intestine. 

114.  The  lesions  were  numerous;  consisting  of  softening, 
thickening,  redness  of  the  mucous  membrane,  small  submucous 

*  Vide  Mémoire  sur  la  Perforation  de  l'Intestin  Grêle,  —  Recherches  sur 
Diverses  Maladies,  page  106,  also  Typhus  Fever,  vol.  il.  chapter  on  Per- 
foration of  the  Small  Intestine.  Though  the  perforation  of  the  small  in- 
testine, since  our  author's  researches,  has  attracted  very  general  attention, 
and  has  been  specially  studied  by  Messrs.  Stokes  and  Graves,  of  Dublin,  a 
summary  of  M.  Louis's  results  may  not  be  unacceptable  to  the  reader. 

He  thinks  that  we  may  regard  the  perforation  of  the  small  intestine  as 
certain,  when  in  the  course  of  an  acute  disease,  and  under  unexpected  cir- 
cumstances, the  patient  is  attacked  with  a  sudden  and  violent  pain  in  the 
abdomen,  which  is  increased  by  pressure,  accompanied  by  a  great  change 
in  the  appearance  of  the  patient,  and  succeeded  by  nausea  and  vomiting. 
He  insists  strongly  on  the  aggravation  of  the  pain  by  pressure,  and  its  rapid 
extension  over  the  abdomen,  as  means  of  diagnosis.  We  conclude  that  per- 
foration has  taken  place  in  the  small  intestine  rather  than  in  any  other  por- 
tion of  the  digestive  tube,  because  in  acute  diseases  the  former  is  incompar- 
ably the  most  frequent.  In  one  hundred  and  fifty  cases  of  phthisis  it  only 
occurred  once.  In  one  hundred  and  sixty  cases  of  other  chronic  diseases, 
two  instances  were  observed.  In  some  rare  examples  the  symptoms  are 
wanting,  when  the  diagnosis  is  of  course  impossible.  Perforations  are,  per- 
haps, more  frequent  than  we  generally  suppose.  Out  of  four  hundred  and 
fifty  post  mortems  there  were  twenty-two  cases  of  perforation  ;  nine  of  the 
small  intestine;  eight  of  the  lungs;  two  of  aneurismal  tumors;  one  of  an 
abdominal  cyst;  one  of  an  hepatic  abscess.  The  examples  of  perforated 
stomach  in  chronic  gastritis  are  numerous.  Vide  Dr.  Abercrombie  on  Ab' 
dominai  Affections. 

Dr.  Stokes,  of  Dublin  has  pi'oposed  a  mode  of  treatment  in  cases  of  per- 
foration, and  in  many  other  circumstances  where  there  is  rapid  prostration 
of  the  vital  powers,  consisting  in  large  and  fi-equcntly  repeated  doses  of 
opium  ;  the  evidence  adduced  in  its  favor  strongly  entitle  it  to  the  practition- 
er's attention.  Vide  Dublin  and  Medical  Journal,  May,  1832.  No.  2.  — 
Cowan. 


Chap.  3.]    SOFTENING  ;  granulations.  79 

abscesses,  semi-cartilaginous  or   tuberculous  granulations  and 
ulcerations. 

115.  The  softening  of  the  mucous  membrane  was  not 
more  common  in  phthisis  than  in  other  chronic  diseases.  Out 
of  ninety-five  cases,  we  have  only  met  it  eight  times,  and 
in  three  of  these  it  was  inconsiderable.  In  five  others,  the 
membrane  was  reduced  to  the  consistence  of  mucus. — (Obs. 
22,  32.)  In  all  of  these  the  softening  occupied  the  whole  of 
the  intestine.  In  three  cases  it  was  associated  with  consider- 
able thickening  and  redness  ;  most  evidently  in  these  circum- 
stances resulting  from  inflammation.  In  a  fourth,  there  was 
thickening  without  redness.  We  have  only  once  found  it 
evidently  thickened,  where  it  was  neither  red  nor  softened 
(Obs.  19). 

In  thirteen  cases  it  was  more  or  less  red,  while  no  alteration 
of  consistence  or  thickness  was  observable  (Obs.  28,  39). 
Among  five  of  these  the  redness  was  universal  ;  while  in 
others  it  was  confined  to  a  limited  portion  ;  usually  the  last 
two  feet  (Obs.  41,  47).  The  mesenteric  vessels  were  never 
loaded  with  blood  ;  so  that  the  redness  probably  most 
frequently  depended  on  some  other  cause  than  simple  con- 
gestion.* 

116.  The  granulations  were,  as  we  have  before  remarked, 
of  two  kinds.  They  sometimes  presented  all  the  characters 
of  tuberculous  matter  ;  in  others  they  were  much  harder  and 
whiter,  offering  almost  the  firmness  and  aspect  of  cartilage. 
The  volume  of  both  was  inconsiderable  ;  on  the  average  that 
of  a  middle-sized  pea,  but  most  frequently  smaller  :  they  were 

*  Laennec,  (page  288),  says  the  mucous  membrane  near  ulcers  is  gen- 
erally pale.  Andral  {Clin.  Med.  vol.  iii.  page  306)  has  found  it  pale  in 
about  one  fifth  of  all  his  cases.  — Cowan. 


80     PATHOLOGICAL  ANATOMY. SMALL  INTESTINE  ;    [Part  I, 

developed  beneath  the  mucous  membrane,  and  almost  invaria- 
bly accompanied  by  ulceration.  The  semi-cartilaginous  gran- 
ulations (Obs.  13,  29,  35),  were  in  general  much  more 
numerous  than  the  others  ;  sometimes  they  were  dispersed 
through  the  whole  of  the  intestine,  with  intervals  varying  from 
one  to  three  inches.  When  thus  universally  present,  they 
increased  in  number  and  size  as  they  approached  the  caecum. 
At  other  times  they  were  much  more  numerous  near  the  duo- 
denum and  in  the  upper  third  of  the  intestine  than  in  that  im- 
mediately succeeding,  and  they  were  wanting  in  the  latter. 
When  small  they  had  scarcely  the  volume  of  a  small  pin's 
head,  were  slightly  adherent  to  the  cellular  layer,  and  the 
mucous  membrane  surrounding  them  was  perfectly  healthy. 
When  about  the  size  of  a  pea,  the  membrane  was  generally 
more  or  less  red,  thickened  and  softened,  or  even  destroyed, 
at  the  point  of  contact.  The  granulations  themselves  then 
began  to  decrease  in  size,  and  the  loss  of  substance  continued 
until  their  complete  destruction,  leaving  the  edges  of  the  ulcer- 
ation indurated,  white  and  opaque  ;  retaining  almost  exactly 
the  characters  of  the  tumor  to  which  they  succeeded  :  thus 
pointing  out  the  nature  of  their  cause.  The  semi-cartila- 
ginous granulations  were  sometimes  seated  upon  the  patches, 
but  more  frequently  in  their  intervals.  They  were  equally 
distributed  over  the  circumference  of  the  intestine.  We  have 
only  remarked  them  immediately  underneath  the  mucous 
membrane  ;  they  never  occupied  the  interstices  of  the  mus- 
cular fibres,  which  induces  us  to  think  that  they  are  simply 
the  morbid  development  of  the  muciparous  glands,  as  the 
situation  of  the  latter  completely  coincides  with  those  just 
described. 

]  17.  We  have  never  found  tuberculous  granulations  equal- 
ly  numerous  with  those  just  described  when  they  existed  in 


Chap.  3.]  ULCERATIONS.  81 

large  quantities.  These  were  also  situated  either  round  the 
ulcerations,  in  their  centre,  or  in  the  interstices  of  the  muscular 
fibres  ;  between  these  and  the  peritoneum  ;*  upon  patches, 
or  in  their  intervals  ;  and  were  almost  constantly  more  numer- 
ous near  the  csecum  than  elsewhere  (Obs.  6,  8,  12,  15,  21, 
27,  he).  We  have  never  found  them  near  the  duode- 
num. 

These  granulations  were  succeeded  by  small  ulcerations, 
produced  by  the  same  process  as  are  tuberculous  excavations 
of  the  lungs.  The  tuberculous  matter  gradually  softened, 
and  the  mucous  membrane  was  proportionably  red,  thickened 
and  softened  in  the  corresponding  point  ;  or  it  was  destroyed, 
and  the  contents  of  the  abscess  were  emptied  on  the  intestinal 
surface,  so  that  inflammation  of  the  mucous  membrane  was 
here  an  effect  and  not  a  cause  of  tubercles. 

118.  We  have  never  seen  tuberculous  matter  occupying 
the  intestinal  mucous  membrane  under  any  other  form  than 
that  of  granulations. 

119.  Either  separately  or  conjoined,  these  two  species  of 
granulations  existed  in  thirty-six  out  of  the  ninety-five  cases 
already  mentioned  ;  and  in  six  of  these  they  were  of  a  semi- 
cartiiaginous  structure,  which  is  much  less  frequently  ob- 
served than  the  other  kind. 

120.  Ulcerations  were  still  more  common,  and  on  this  ac- 
count seemed  very  often  unconnected  with  either  kind  of 
granulation.  We  have  remarked  them  in  different  propor- 
tions in  seventy-eight  instances,  making  them  more  than  twice 
as  frequent  as  granulations,  being  present  in  nearly  five  sixths 

*  These  differences  iu  the  situation  of  the  two  kinds  of  granulations  prove 
that  they  occupy  different  tissues.  —  Louis. 


82   PATHOLOGICAL    ANATOMÏ. SMALL  INTESTINE  ;    [Pait  I, 

of  the  cases.*  This  proportion  is  rather  different  from  that  of 
Bayle,  who  has  met  this  alteration  in  only  the  sixty-seven 
hundredths.  This  difference,  however,  ought  not  to  cause 
any  doubt  as  to  our  own  accuracy  :  we  have  probably  em- 
ployed more  time  in  properly  cleaning  the  small  intestine,  and 
in  scrupulously  examining  it  throughout  its  whole  extent  ;  in 
this  way  the  smallest  ulcerations,  which  can  only  be  detected 
when  the  mucous  membrane  is  well  washed,  would  not  have 
been  overlooked  ;  and  to  this  more  than  to  any  other  cause 
our  difference  may,  we  think,  be  attributed. 

121.  With  some  few  exceptions,  the  number,  dimensions, 
and  depths  of  the  ulcerations,  increased  as  they  approached 
the  caecum.  Supposing  the  small  intestine  to  be  divided  into 
three  equal  portions,  in  the  majority  of  cases  ulcerations  only 
existed  in  the  lower  third,  or  in  this  and  the  middle  third.  It 
was  much  less  common  to  find  them  occupying  the  whole  of 
the  intestine.  This  was,  however,  the  case  in  rather  more 
than  one  sixth  of  the  examples  ;  in  only  three  instances  have 
we  seen  ulcerations  confined  to  the  middle  third. 

12-2.  When  small,  they  were  almost  exclusively  situated 
opposite  the  mesentery,  in  points  corresponding  to  the  agmi- 
nated  glands  or  patches,  which  were  themselves  destroyed. 
In  their  maximum  of  development  they  occupied  the  whole 
circumference  of  the  intestine. 

Their  dimensions  varied  from  a  line  to  five  or  six  inches  in 
superficies.  Occasionally  the  same  individual  presented  sev- 
eral of  the  larger  ulcerations  (Obs.  4),  while  in  others  the 
smaller  were  alone  present,  or  there  was  only  a  single  ulcer 
(Obs.  23). 

*  Andral,  (Clin.  Med.  vol.  iii.  page  175),  out  of  ail  the  phthisical  patients 
entering  the  wards  oi'  M.  Lerminicr  during  five  years,  found  the  intestines 
sound  in  one  fifth  only.  —  Cowan. 


Chap.  3.]         ulcerations:   size;  color,  &.c.  83 

123.  Their  form  for  the  most  part,  pointed  out  their  origin, 
and  was  as  variable  as  their  dimensions.  When  small,  they 
were  rounded,  as  are  those  which  result  from  the  softening  of 
the  granulations.  When  of  medium  size  they  presented  the 
elliptical  figure  of  the  patches,  whose  situation  they  occupied  ; 
and  this  appearance  was  the  most  usual.  Next  to  this,  the 
circular  form  predominated  (Obs.  31,  38,  43).  The  lineary 
was  the  most  unfrequent  ;  we  have,  however,  seen  it  in  seven 
instances,  and  almost  always  in  the  upper  half  of  the  intes- 
tines ;  in  these  cases  the  ulceration  was  from  an  inch  to  an 
inch  and  a  half  in  length,  and  a  line  and  a  half  in  breadth  at 
its  centre,  gradually  narrowing  towards  the  extremities. 

124.  The  color  of  these  ulcerations  was  as  variable  as  their 
other  properties.  Usually  whitish  when  small,  they  were 
often  of  a  grey  color  mingled  with  red,  when  their  dimensions 
were  more  or  less  considerable.  Sometimes  also,  and  this  pe- 
culiarity was  almost  confined  to  the  lineary  ulcerations,  they 
were  of  a  blackish  or  reddish  brown  color. 

125.  Their  structure  varied  according  to  their  extent  and 
duration.  When  small,  and,  doubtless,  recent,  the  denuded 
submucous  cellular  tissue  was  slightly  thickened,  smooth,  and 
no  evident  alteration  of  the  muscular  layer  was  observable. 
When  larger  their  aspect  was  less  uniform  ;  some  presented 
an  unequal  surface,  formed  by  the  more  or  less  thickened  sub- 
mucous layer  and  fragments  of  the  mucous  membrane.  In 
others,  no  trace  of  the  latter  existed  ;  but  the  cellular  layer 
was  alternately  thin  or  thick,  partially,  or  even  wholly  de- 
stroyed, and  the  muscular  coat  exposed  ;  the  latter  also  became 
in  its  turn  more  or  less  thickened,  rough,  of  a  greyish  or  whitish 
color,  and  interspersed  at  times  with  tuberculous  granulations. 
This  increased  thickness  was  often  conjoined  with  partial 
thinning  of  the  membrane.      Its  complete   destruction  was 


84    PATHOLOGICAL    ANATOMY.  SMALL  INTESTINE  ;    [Part  I, 

much  less  frequently  observed  ;  so  that  in  proportion  as  any- 
one of  the  tissues,  entering  into  the  formation  of  the  intestinal 
parietes,  was  denuded,  it  became  someivhat  thickened  and 
finally  ulcerated. 

126.  The  large  ulcerations  were  frequently  the  result  of 
the  junction  of  smaller  ones  ;  a  fact  easily  demonstrated  when 
the  latter  were  numerous  and  situated  upon  the  patches. 
There  might  then  be  observed  softened  tubercles,  with  small 
circular  ulcerations  separated  by  entire  or  partially  destroyed 
bands.  In  others,  no  remnant  of  these  divisions  remained, 
the  cellular  membrane  was  completely  denuded,  more  or  less 
thickened,  and  presented  small,  round-shaped  depressions  of 
variable  depth,  corresponding  without  doubt  to  the  partial  ul- 
cerations just  described.  Lastly,  in  a  third  division  of  similarly 
formed  ulcerations  the  submucous  layer  was  either  in  part  or 
wholly  destroyed,  and  the  muscular  coat  denuded,  uneven  and 
thickened. 

The  following  case  furnishes  an  example  of  most  of  the 
preceding  alterations. 


FOURTH    OBSERVATION. 

A  HOUSE  painter,  aged  62,  entered  the  hospital  of  La  Char- 
ité, July  25th,  1824,  and  died  on  the  first  of  August  following. 
Born  of  healthy  parents,  and  himself  of  naturally  thin,  spare 
habit,  dated  his  illness  and  diarrhosa  five  months  previously. 
The  latter  had  been  violent,  causing  at  first  twenty,  or  a  still 
greater  number  of  stools  in  the  twenty-four  hours;  these  were 
frequently  accompanied  by  violent  colic;    cough  had  been 


Chap.  3.]  ULCERATIONS.  85 

present  from  the  middle  of  the  fourth  month.  Since  then  the 
aphonia  had  been  more  or  less  complete,  and  he  complained 
of  a  sense  of  dryness  in  the  larynx.  Diminution  of  appetite  al- 
most from  the  commencement;  the  anorexia  had  subsequently 
increased  ;  and,  after  the  fourth  month,  the  cough  occasionally 
excited  nausea.  Thirst,  urgent  from  the  third  month.  Had 
experienced  no  rigors  or  sense  of  heat  with  the  exception 
of  the  eight  days  preceding  his  entrance  into  the  hospital  ; 
emaciation  from  the  first. 

On  the  25th  of  July,  great  debility  ;  memory,  good;  breath- 
ing, slightly  accelerated  ;  cough,  moderately  frequent  ;  expec- 
toration, pretty  abundant,  opaque,  greenish,  not  striated,  and 
with  ragged  edges  (déchiquetés).  Percussion  of  chest  good; 
tracheal  respiration  under  the  left  clavicle  ;  coarse  and  strong 
under  the  right,  but  without  any  gurgling  (gargouillement). 
Apyrexia;  skin,  cool;  pulse,  calm.  Tongue,  rather  pale 
than  otherwise,  nearly  natural  ;  no  appetite  ;  thirst,  moderate  ; 
deglutition,  rather  difficult  ;  occasional  sense  of  oppression  in 
epigastrium  ;  three  liquid  stools. 

On  the  31st,  at  the  time  of  the  visit,  marked  change  in 
features,  expression  of  uneasiness  and  suffering  ;  tongue  dry  ; 
abdomen  very  hot,  of  natural  form  and  volume.  For  the  last 
hour  had  experienced  acute  pains  in  the  region  of  the  gall-blad- 
der, greatly  increased  by  pressure.  The  stools  had  become 
very  frequent,  and  the  pulse  and  breathing  much  accelerated. 

The  same  symptoms  continued  during  the  day,  and  the 
patient  expired  at  four  the  next  morning. 

Opening  of  the  corpse  tiventy-eight  hours  after  death. 

Exterior.  —  Extreme  emaciation. 

Head. —  A  good  deal  of  infiltration  beneath  the  upper  por- 
tion of  arachnoid  :  three  spoonsful  of  clear  serosity  in  each 


86      PATHOLOGICAL    ANATOMY.  SMALL  INTESTINE  ;    [Part  I, 

lateral  ventricle.  One  in  the  lower  occipital  fossae.  The 
septum  lucidum  very  thin  and  distended  by  the  same  fluid 
which  existed  in  the  middle  ventricle  ;  in  all  about  a  drachm. 
Cerebral  substance  moderately  injected. 

Neck.  —  The  inferior  half  of  the  laryngeal  surface  of  the 
epiglottis  was  slightly  injected,  and  had  some  superficial 
ulcerations.  A  very  small  one  was  found  at  the  junction  of 
the  vocal  cords.  The  mucous  membrane  of  the  trachea  was 
red  without  other  alteration. 

Chest.  —  The  left  lung,  which  was  adherent  to  the  costal 
and  diaphragmatic  pleurae  by  an  abundant  cellular  tissue,  was 
congested  at  its  base,  and  presented  in  its  summit  a  middle- 
sized  tuberculous  excavation,  nearly  empty.  Its  parietes  were 
not  lined  by  a  false  membrane,  but  principally  composed  of  tu- 
bercles, granulations,  and  a  grey  substance  approaching  to  black, 
which  was  abundantly  scattered  throughout  the  remainder  of 
the  upper  lobe.  The  same  alterations,  though  less  numerous, 
were  found  in  the  lower  lobe.  There  was  no  cavity  in  the  right 
lung,  but  a  small  number  of  tubercles  or  granulations  with  some 
adhesions.  On  the  same  side  the  bronchia  were  of  a  pale  pink 
color  ;  on  the  left,  where  they  freely  communicated  with  the 
excavation,  they  were  of  a  very  dark  red.  The  bronchial 
glands  were  not  tuberculous  ;  heart,  sound  j  aortic  valves, 
rather  tense  and  thickened  on  their  free  edges. 

Abdomen.  —  A  little  limpid,  reddish-colored  serosity  in  the 
lumbar  regions  ;  a  large  glass  full  of  thick,  yellow-colored  in- 
odorous pus  between  the  bladder  and  rectum.  No  where  any 
trace  of  false  membrane.  The  mucous  membrane  of  the 
stomach  was  very  thin,  almost  transparent,  and  as  soft  as 
mucus  in  the  upper  portion  of  the  great  cul-de-sac,  where  the 
subjacent  vessels  were  of  a  brownish  color  and  much  enlarged. 
Elsewhere  it  was  greyish,  more  or  less  mamillated,  of  normal 


Chap.  3.]  ULCERATIONS.  87 

thickness  and  consistence.  Nothing  remarkable  in  the  duode- 
num. The  small  intestine  was  rather  larger  than  natural,  offer- 
ing externally  many  grey,  bluish-colored  spots,  and  containing 
a  large  quantity  of  turbid,  reddish,  and  moderately  thick  fluid. 
Supposing  it  divided  into  five  equal  parts,  the  mucous  mem- 
brane was  healthy  in  the  first  and  last.  In  the  remainder 
there  were  numerous  ulcerations,  almost  all  situated  parallel  to 
the  direction  of  the  valvulae  conniventes.  The  largest  were 
in  the  centre  of  the  intestine,  interesting  the  whole  of  its  cir- 
cumference, and  leaving  the  muscular  coat  exposed.  Two 
among  them  presented  a  superficies  of  from  four  to  six  inches  ; 
they  were  greyish  colored  and  rugged.  The  muscular  coat 
in  the  same  point  was  three  quarters  of  a  line  thick,  its  fibres 
were  more  brittle  and  less  flexible  than  natural.  Above  and 
below  this  portion  of  the  gut,  ulcerations  existed,  (not  complete- 
ly encirchng  the  intestine),  whose  edges  were  thick,  but  whose 
centres  were  very  thin,  so  that  the  muscular  coat  seemed  cut 
obliquely.  The  bottom  of  several  consisted  wholly  of  perito- 
neum, which  was  itself  sometimes  destroyed,  and  perforation 
had  taken  place  in  two  spots.  Round  one  of  these  perfora- 
tions the  serous  membrane  was  of  a  livid  red  color,  for  the 
space  of  four  or  five  lines,  exceedingly  thin,  and  in  all  re- 
spects resembhng  those  perforations  which  take  place  in  acute 
diseases.  Around  the  other  it  was  of  natural  color  and  less 
attenuated,  as  if  rather  the  result  of  tearing,  (though  the 
greatest  precautions  were  employed),  than  of  any  other 
cause.  The  contents  of  the  large  intestine  were  similar  to 
those  of  the  small.  The  muscular  coat  was  denuded  in  the 
whole  circumference  of  the  cœcum,  and  for  about  seven 
inches  of  the  ascending  colon.  It  was  of  greyish  color,  with 
partial  but  inconsiderable  loss  of  substance,  and  one  line 
thick.     Below  this,  even  to  the  middle  of  the  transverse  colon, 


88    PATHOLOGICAL    ANATOMY.  SMALL  INTESTINE  ;    [Part  I, 

there  were  other  very  extensive  ulcerations,  exactly  similar  to 
the  one  described,  leaving  the  intervening  mucous  membrane 
healthy.  This  last  was  pale  and  slightly  softened  in  the  de- 
scending colon  and  rectum.  The  greater  part  of  the  mesen- 
teric glands  were  much  increased  in  volume  and  transformed 
into  tuberculous  matter.  Some  among  them  presented,  con- 
joined with  this,  variably  sized  masses,  of  a  white,  opaque, 
shining  and  resisting  substance,  in  every  respect  cancerous. 
The  other  abdominal  viscera  were  healthy. 

127.  Notwithstanding  the  very  careful  examination  of  the 
intestinal  tube,  and  although  one  of  the  perforations  exactly 
coincided  in  its  symptoms  and  pathological  characters  with 
what  takes  place  in  the  best  observed  and  described  acute 
cases  of  this  description,  we  cannot  in  the  present  instance 
suppose  it  to  have  existed  during  life.  It  is  true  that  an 
acute  pain  was  felt  in  the  region  of  the  gall-bladder  twenty- 
four  hours  before  death  ;  the  pulse  became  accelerated,  the 
abdomen  was  hot,  and  a  quantity  of  pus  was  found  in  the 
peritoneal  cavity  ;  in  a  word,  there  was  peritonitis.  But  the 
pus  was  without  odor,  of  natural  color,  and  had  none  of  those 
properties  which  accompany  perforation  of  the  small  intestine, 
(properties  so  marked  in  respect  to  odor  and  color,  that  they 
are  almost  sufficient  of  themselves  to  indicate  perforation)  ; 
there  was  not  the  slighest  trace  of  the  turbid,  dirty-colored 
fluid  of  the  small  intestine  in  the  peritoneal  cavity  ;  so  that 
this  individual  fact  seems  rather  an  example  of  one  of  those 
cases  of  peritonitis  which  come  on  in  the  last  stage  of  phthisis 
(188),  than  true  perforation  of  the  intestine.  At  all  events, 
this  observation  is  extremely  interesting,  from  the  number  and 
extent  of  the  ulcerations  in  both  intestines  ;  from  the  thickened 
state  of  the  corresponding  muscular  coat  ;  from  its  diminished 


Chap.  3.]  ULCERATIONS.  89 

thickness  and  complete  destruction  in  the  centre  of  others, 
with  exposure  of  the  peritoneum  and  perforation,  either  actu- 
ally arrived,  or  on  the  verge  of  taking  place. 

Let  us  also  take  notice  that  there  were  no  tuberculous 
granulations  in  the  substance  of  the  muscular  coat.  Were 
this  more  frequently  the  case  it  is  probable  that  its  entire  de- 
struction and  peritoneal  perforation  would  be  less  rarely  ob- 
served. But,  as  we  have  already  remarked  (125),  muscular 
fibres,  instead  of  following  the  destruction  of  the  mucous  and 
cellular  membranes,  become  gradually  thicker,  only  yielding 
after  a  greater  or  less  space  of  time,  and  then  in  comparatively 
few  instances. 

128.  The  parts  immediately  surrounding  the  ulcerations 
were  sometimes  on  their  usual  level,  but  in  general  were  more 
or  less  raised.  When  the  ulcerations  were  small  and  circular, 
the  mucous  and  cellular  tunics  forming  their  edges  were  very 
slightly  thickened.  If  they  resulted  from  the  semi-cartilagi- 
nous granulations,  the  edges  were  thick  proportionably  to  the 
progress  the  latter  had  made.  When  large  and  still  recent, 
the  submucous  layer  not  being  destroyed,  their  circumference 
was  rugged  and  of  variable  thickness,  arising  in  many  cases 
from  the  presence  of  a  certain  number  of  softened  tubercles. 
In  general,  the  surrounding  mucous  membrane  was  more  or 
less  red  and  softened. 

Besides  the  preceding  alterations,  there  were  occasionally 
minute  abscesses,  of  the  dimensions  of  a  pea,  formed  in  the  sub- 
mucous cellular  tissue.  These  were  sometimes  present  when 
neither  ulcerations  nor  tuberculous  granulations  existed  in  the 
small  intestine.  Their  parietes  were  at  times  smooth,  so  that 
they  seemed  rather  the  result  of  phlegmonous  inflammation  than 
of  softened  tubercle.    It  is  proper,  however,  to  observe,  that  we 

L 


90      PATHOLOGICAL    ANATOMY. SMALL  INTESTINE.    [Parti, 

have  scarcely  found  them  except  in  phthisical  patients  ;  and 
in  the  two  instances  where  they  existed  after  other  diseases, 
their  contents  were  composed  of  a  very  tenacious,  yellowish, 
and  semi-transparent  substance. 

129.  When  the  small  intestine  was  healthy,  or  presented 
very  few  morbid  changes,  it  contained  a  variable  quantity  of 
mucus,  of  different  color  and  consistence,  and  sometimes  it 
was  stained  with  blood.  When,  however,  the  ulcerations 
were  large  and  numerous,  instead  of  mucus,  there  was  a  tur- 
bid, dirty,  red-colored  or  greyish  fluid  of  variable  consistence, 
very  similar  to  what  we  have  described  in  the  last  observa- 
tion ;  it  had  strong  odor,  much  resembling  that  of  animal  sub- 
stances in  maceration  (Obs.  14). 

IN    PATIENTS    WHO    DIED    OF    OTHER    DISEASES. 

130.  Many  of  the  morbid  alterations  now  described,  as  the 
softening,  thickening,  redness  of  the  mucous  membrane  and 
semi-cartilaginous  granulations,  are  common  to  phthisis  and  to 
a  great  number  of  other  chronic  and  acute  affections  ;  but  the 
semi-cartilaginous  granulations  are  more  frequent  in  phthisis 
than  in  any  other  circumstances.  The  tuberculous  granula- 
tions and  ulcerations  appear  peculiar  to  this  disease.  We 
have  never  remarked  the  former  except  in  phthisis  ;  and  if  it 
is  not  rigorously  correct  to  say  that  ulcerations  of  the  small 
intestine  are  exclusively  found  in  this  affection,  exceptions  are 
so  rare  that  the  proposition  is  almost  literally  true.  Out  of 
eighty-five  cases,  consisting  of  various  chronic  affections,  we 
have  only  met  six  where  the  small  intestine  was  ulcerated. 
Three  an)ong  these  were  in  individuals  whose  lungs  offered 
either  tubercles  or  tuberculous  excavations.  Among  the 
three  others,  one  was  that  of  a  woman  whose  principal  affec- 
tion was  gastritis  ;  the  other  two  were  cases  of  dysentery.     In 


Chap.  3.]        LARGE    INTESTINE  ;    REDNESS,  &£C. 


91 


the  three  instances  the  ulcerations  were  small  and  few  in  num- 
ber ;  so  that,  if  every  kind  of  ulceration  of  the  small  intestine  is 
not  absolutely  peculiar  to  phthisis,  we  may  consider  the  asser- 
tion correct  for  ulcers  of  a  certain  size  ;  for  we  are  here  only 
referring  to  chronic  diseases,  and  not  including  typhus  fever.* 


ARTICLE    V. 


LARGE  INTESTINE. 


131.  With  the  exception  of  the  semi-cartilaginous  granula- 
tions, this  portion  of  the  intestinal  canal  presented  lesions 
similar  to  those  we  have  just  described.  We  shall,  therefore, 
only  insist  on  their  peculiarities. 

132.  The  whole  of  the  mucous  membrane  was  red,  in 
twenty-seven  out  of  the  ninety-five  cases  we  are  considering  ; 
that  is,  in  rather  more  than  one  fourth.  In  twelve  of  these  the 
redness  was  interrupted  ;  in  fifteen  it  was  continuous  through- 
out; and,  when  this  was  the  case,  it  was  generally  very  in- 
tense. With  three  exceptions,  it  coincided  with  very  marked 
softening  of  the  mucous  membrane,  which  was  reduced  to  the 
consistence  of  mucus,  and  could  only  be  removed  in  this  form. 
It  was  often  thickened,  and  more  frequently  ulcerated. 

*  These  results  are  of  a  highly  interesting  nature,  and  not  without  marked 
advantages,  both  for  diagnosis  and  treatment.  In  cases  of  chronic  affections 
of  the  small  intestine,  our  great  object  would  be  (o  decide  on  the  presence  or 
absence  of  phthisis.  In  the  latter  case,  the  presumption  of  ulcerations  not 
existing  would  certainly  be  justifiable,  and  greatly  increase  the  probability 
of  efficacious  treatment.  During  the  eight  years  which  have  elapsed  since 
the  publication  of  this  work,  M.  Louis  has  not  examined  a  single  subject 
who  died  from  a  chronic  disease  and  presented  ulcerations  in  the  small  in- 
testine, in  which  he  did  not  find  tubercles  in  the  lungs.  Vide  Examen,  de 
l'Examen,  page  18.  —  Cowan. 


92     PATHOLOGICAL  ANATOMY. LARGE  INTESTINE  ;    [Part  I, 

133.  Thickening  was  present  even  when  the  natural  white 
color  of  the  membrane  was  retained  ;  but  was  then  combined 
with  softening  and  a  certain  number  of  ulcerations. 

In  comparing  this  and  the  preceding  paragraph,  we  per- 
ceive that  the  thickening  of  the  mucous  membrane  of  the  large 
intestine  was  always  united  to  some  other  alteration,  and  most 
usually  to  that  of  softening. 

134.  Softening  was  then  very  frequently  present.  It  was 
observed  not  only  in  those  cases  where  the  mucous  membrane 
was  red  and  thickened,  but  even  where  it  had  preserved  its 
natural  color  and  thickness.  We  have  found  it  sixty-two  times 
either  occupying  the  totality,  or  a  considerable  part  of  the 
intestine. 

In  numerous  instances  the  red  and  softened  mucous  mem- 
brane was  more  or  less  extensively  mamillated  (Obs.  17)  ;  or  it 
was  more  or  less  completely  destroyed  in  innumerable  minute 
portions,  producing  an  undulated  aspect,  sometimes  through 
its  whole  extent.  In  two  instances  it  was  destroyed  over  a 
surface  of  ten  inches  ;  and,  in  consequence  of  the  slightly 
pink  tinge  of  the  submucous  tissue  corresponding  to  this  enor- 
mous loss  of  substance,  it  would,  without  great  attention  on 
our  part,  have  escaped  notice.  Beyond  the  limits  of  this  de- 
struction the  cellular  tissue  was  not  sensibly  modified,  and  the 
membrane  may,  perhaps,  have  been  removed,  simply  by  the 
friction  occasioned  by  the  passage  of  faecal  matter.  This  is 
rendered  more  probable  from  the  fact  that,  in  extreme  states 
of  softening  of  the  mucous  membrane  of  the  colon,  the  passing 
of  the  back  of  a  scalpel  over  it  is  sufficient  to  remove  it  en- 
tirely. 

135.  The  cellular  tissue  was  usually  opaque  in  these  cases; 
its  thickness  two,  three,  or  four  times  greater  than  natural  (Obs. 
17).     In  some  cases,  as  we  have  mentioned  (134),  it  was  of 


Chap.  3.]    SOFTENING,  &;c.  ;  causes  of?         93 

a  light  rose  color,  while  in  the  majority  it  retained  its  usual 
whiteness. 

This  last  fact  appears  very  remarkable  ;  for,  as  will  here- 
after be  shown,  the  softening  of  the  mucous  membrane  was, 
in  a  great  number  of  instances,  an  evident  result  of  inflamma- 
tion, which  only  dated  a  kw  days  previous  to  the  death  of  the 
patient.  The  thickening  of  the  submucous  cellular  tissue  was 
probably  consecutive  ;  it  was  certainly  of  the  same  nature, 
and  yet  it  is  difficult  to  imagine  a  membrane  thickened  by 
recent  and  acute  inflammation,  retaining  its  natural  paleness. 
This  fact,  with  many  others,  shows  that  the  thickness  of  our 
tissues  is  one  of  the  most  important  circumstances  to  be  noticed, 
and  that  to  confine  ourselves  to  the  description  of  the  color  of 
membranes  is  often  useless,  and  even  a  cause  of  error,  to  tlrose 
who  might  draw  conclusions  from  such  imperfectly  described 
facts. 

136.  It  may  be  asked,  is  the  cause  of  this  softening  con- 
stantly the  same  ?  When  united  to  redness  and  thickening  it 
can  scarcely  be  doubted  that  it  has  an  inflammatory  origin. 
This  is  also  probably  the  case  when  thickening  exists  alone, 
for  paleness  of  inflamed  structures  takes  place  sooner  or  later, 
as  is  exemplified  in  the  various  shades  of  color  of  hepatized 
lung. 

But  when  softening  is  present,  without  any  change  of  color 
or  thickness,  is  it  then  the  effect  of  inflammation  ?  This,  as  it 
seems  to  us,  is  also  far  from  impossible  ;  but  at  the  same  time 
that  it  is  so,  is  not  incontestable,  for  many  organs  are  fre- 
quently softened  when  we  cannot  suppose  inflammation  to 
have  been  present.  Thus,  in  typhus  fever,  and  in  many 
chronic  diseases,  the  heart  is  often  softened  and  its  color  in- 
creased, without  any  assignable  cause.  The  spleen  presents 
in  numerous  instances  a  state  of  extreme  softening,  which  we 


94     PATHOLOGICAL    ANATOMY.  LARGE  INTESTINE  ;    [Part  1, 

have  no  right  to  attribute  to  inflammation.  On  the  other 
hand,  it  ought  to  be  noticed  that  continuous  with  a  red  and 
softened  portion  of  mucous  membrane,  we  often  find  another 
equally  softened,  but  without  redness.  If  the  first,  therefore, 
is  inflammatory,  it  is  probable  that  the  other  is  so  also  ;  but  it 
is  a  mere  probability,  and  fresh  facts  are  necessary  to  decide 
the  question. 

137.  But  at  what  degree  of  softening  does  disorganization 
take  place  ?  We  are  not  acquainted  with  any  fact  which  can 
solve  this  problem.  It  appears  to  us,  however,  infinitely  pro- 
bable, that  very  considerable  softening  may  exist,  without  the 
affected  tissues  becoming  disorganized  ; —  the  condition  of  the 
spleen  in  typhus  fever  is  very  favorable  to  this  opinion.  In 
fact,  in  a  certain  number  of  individuals  who  have  died  after  a 
very  protracted  form  of  this  disease,  we  have  found  the  spleen 
voluminous  and  firm  ;  and  since  its  softening  is  an  almost  con- 
stant phenomenon  in  typhus,  and  that  to  an  extreme  degree, 
we  must  admit  that  this  had  taken  place  in  some  of  the  cases 
referred  to,  and,  consequently,  that  the  spleen  had  regained 
its  consistence,  and  had  not  been  disorganized. 

138.  When  describing  the  symptoms  farther  on  (264),  we 
shall  find,  as  we  have  already  pointed  out  (135),  that  the  in- 
flammation producing  the  pulpy  softening  of  the  mucous  mem- 
brane of  the  large  intestine  is  developed  only  a  {ew  days 
before  deatli,  as  is  the  case  in  inflammation  of  the  pulmon- 
ary parenchyma,  the  pleura,  and  the  mucous  membrane  of 
the  stomach. 

139.  There  were  thirteen  examples  of  tuberculous  granu- 
lations ;  (that  is,  they  existed  in  about  one-eighth  of  the 
cases).  These  were  situated  either  in  the  centre  or  circum- 
ference of  the  ulcerations,  and  not  in  their  intervals. 


Chap.  3.]  ULCERATIONS  ;  SIZE.  95 

We  have  never  observed  the  semi-cartilaginous  granula- 
tions, 

140.  Ulcerations  were  frequent.  They  were  present  in 
seventy  cases,  which  makes  them  nearly  as  common  here  as 
in  the  small  intestine  ;  and  since  softening  of  the  mucous  mem- 
brane often  existed  without  ulceration,  we  have  necessarily 
very  rarely  found  this  membrane  perfectly  healthy  in  its  whole 
extent.     It  was  so  only  tliree  times. 

141.  Usually  the  ulcerations  were  small,  from  three  to  six 
lines,  or  less,  in  diameter.  The  largest,  (and  we  have  already 
seen  how  considerable  their  dimensions  were  occasionally), 
formed  only  about  one  fourth  of  the  cases.  The  smaller,  in 
ten  cases,  were  almost  uniformly  distributed  throughout  the 
whole  of  the  intestine.  When  more  considerable,  (one  or 
two  inches,  or  rather  more  in  surface),  this  was  the  case 
in  only  one  instance.  In  other  examples,  the  number  of 
the  ulcerations  diminished  from  the  caecum  to  the  ascending 
colon,  and  from  the  transverse  to  the  rectum,  in  the  ratio  of 
seventeen,  eleven,  eight,  four.  If  we  would  now  know  the 
aggregate  of  cases  in  which  ulcerations  were  present  in  each 
division  of  the  intestine,  (including  the  small  ulcerations),  the 
respective  figures  for  the  caecum,  the  ascending,  transverse,  de- 
scending colon  and  rectum  will  be  thirty-four,  thirty-seven, 
twenty-five,  eight,  thirty-two  cases,  that  is,  in  an  equal  propor- 
tion of  cases  they  are  nearly  equally  common  in  the  caecum 
and  rectum.  But  here  the  analogy  ceases  ;  for  the  differ- 
ence, as  to  the  size  and  number  of  the  ulcerations,  was  very 
great  (142). 

When  small,  they  were  usually  rounded,  with  flattened 
edges,  as  if  artificially  produced.  Their  bottom  was  greyish, 
approaching  to  black,  sometimes  but  rarely  of  a  pink  color;  this 
last  tint  would  have  often  led  us  to  overlook  them,  had  we  not 


96    PATHOLOGICAL    ANATOMY. LARGE  INTESTINE  ;    [Part  I, 

been  in  the  habit  of  scrupulously  washing  the  intestine.  They 
"  were  lined  by  the  cellular  tissue,  either  thickened  or  much 
thinned,  and  in  three  instances  only,  by  the  healthy  muscular 
coat  ;  which  latter  disposition  we  have  not  yet  observed  in 
similarly  sized  ulcerations  in  the  small  intestine. 

Instead  of  a  rounded  form,  both  the  small  and  middle-sized 
ulcerations  were  sometimes  much  elongated,  being  from  one  to 
two  inches  in  length  by  two  or  three  lines  wide  ;  or  even  less. 
In  direction,  they  were  either  transverse,  longitudinal  or  ob- 
lique. These  varieties  of  form  were  sometimes  all  combined 
when  the  ulcerations  were  numerous  and  clustered  together, 
and  the  intervening  mucous  membrane  more  or  less  thickened, 
the  general  aspect  very  much  resembled  the  chapped  integu- 
ments of  the  hand. 

142.  The  form  of  the  large  ulcerations  was  irregular,  in- 
dentated  or  radiated  ;  often  attacking  the  whole  circumfer- 
ence of  the  caecum,  ascending,  transverse  colon  and  rectum. 
They  not  only  very  frequently  extended  round  the  caecum  and 
ascending  colon,  but  an  ulcer  occupied  longitudinally  a  space 
of  from  eight  to  nine  inches  or  more  (Obs.  4,  12).  Now 
and  then,  in  the  midst  of  these  immense  ulcerations,  there 
were  zones  of  intestine  perfectly  healthy,  except  a  slight  and 
partial  softening  of  the  mucous  membrane;  here  and  there 
were  seen  small  insulated  portions,  formed  by  the  more  or 
less  thickened  fragments  of  the  mucous  and  cellular  tissues. 
The  other  divisions  of  intestine  have  in  no  instance  pre- 
sented ulcerations  of  equal  dimensions.  The  largest  we  have 
ever  observed  in  the  rectum,  were  from  an  inch  and  a  half 
to  two  inches  in  length,  encircling  the  gut,  and  situated  im- 
mediately above  the  anus. 

Both  the  large  and  middle-sized  ulcerations  were  of  a  grey- 
ish color.     They  were  sometimes  lined  by  the  more  or  less 


Chap.  3.]  ULCERATION,   SIZE,  FORM,  COLOR.  97 

thickened,  indurated,  and  easily  torn  sub-mucous  membrane. 
This  was  much  softened  only  twice  ;  most  frequently  it  was 
destroyed,  and  the  muscular  membrane  exposed.  This  de- 
struction was  almost  invariably  complete  and  universal  in  the 
large  ulcerations.  The  muscular  layer  under  these  circum- 
stances was  always  thickened  more  than  a  line,  and  of  a 
variably  deep  grey  color;  its  fibres  were  more  or  less  brittle 
and  indurated,  forming  prominent  fasciculi,  sometimes  with 
tuberculous  granulations  in  their  interstices,  and  presenting,  in 
some  points,  a  commencement  of  destruction. 

Examples  occurred,  where  the  mucous  membrane  and  the 
cellular  membrane  under  it  were  detached  to  a  greater  or  less 
extent  around  the  ulcerations,  or  they  formed  elevations  which 
connected  the  ulcers  together. 

143.  When  the  ulcerations  were  very  large  and  numerous, 
and  the  muscular  coat  extensively  denuded,  there  was  fre- 
quently an  odor  similar  to  that  from  animal  substances  which 
have  been  some  time  in  maceration.  The  faeces  were  reddish, 
turbid,  and  liquid,  often  resembling  putty  in  color.  A  few 
days  previous  to  death,  the  stools  sometimes  presented  a  similar 
odor  and  color.  Were  the  ulcerations  few  in  number,  of  mo- 
derate size,  and  limited  to  the  caecum  or  commencement  of  the 
colon,  the  faeces  were  often  soft,  dirty  colored,  and  sometimes 
smeared  with  blood  in  these  parts  ;  while  in  the  rectum  they 
were  very  dark,  or  of  a  bright  yellow  color.  We  must  there- 
fore conclude,  that  with  some  rare  exceptions,  it  is  impossible 
to  appreciate  the'state  of  the  mucous  membrane  of  the  large 
intestine,  by  means  of  the  faecal  discharges,  except  in  very 
rare  cases.* 

*  Dr.  Abercrombie,  in  his  valuable  work  on  Abdominal  Diseases,  arrives 
at  nearly  similarconclusions.  —  Cowan. 
M 


93     PATHOLOGICAL  ANATOMY. SMALL  INTESTINE.     [Part  I^ 

144.  Intestinal  ulcerations  were  often,  at  least  in  their  origin, 
■independent  of  inflammation.  This  was  evidently  the  case 
■with  a  great  number  of  those  in  the  small  intestine  ;  they  were 
the  result  of  softened  tubercles  ;  for  the  development  of  the 
latter  could  not  be  attributed  to  inflammation,  since  so  long  as 
they  remain  unsoftened,  the  mucous  membrane  covering  them 
continued  healthy.  Far  from  being  the  cause,  the  inflamma- 
tion of  the  mucous  membrane  was,  as  we  have  already  seen 
(117),  subsequent  to  the  presence  of  the  granulations.  The 
same  remark  is  equally  applicable  to  some  cases  of  ulceration 
of  the  large  intestine. 

Where  softened  tubercle  could  not  be  considered  the  cause, 
it  would  still  be  difficult  to  regard  ulceration  as  simply  the 
effect  of  inflammation,  which  does  not  usually  take  place  in 
isolated  patches  on  a  mucous  surface.  Of  this  fact  we  have 
we  think  afforded  a  proof  for  the  colon,  when  speaking  of 
the  softenino-  with  redness  and  thickenino;  of  its  mucous  mem- 
brane,  which  almost  invariably  extends  to  its  whole  surface. 
As  to  the  small  intestine,  we  will  remark,  that  while  distinct 
traces  of  inflammation  are  ranch  less  common  than  in  the 
colon,  its  ulcerations  are  still  more  frequent  ;  and  that  where 
inflammation  appeared  to  be  their  cause,  it  had  still  a  peculiar 
character,  since  the  ulcers  are  most  generally  limited  to  the 
patches. 

These  reflections  are  strengthened  by  what  we  have  said 
respecting  the  extreme  rareness  of  ulcerations  of  the  small 
intestine  in  all  chronic  diseases  except  phthisis;  while  simple 
inflammation  of  the  mucous  membrane  is  quite  as  frequendy 
observed  in  one  case  as  the  other.* 

*  These  remarks  arc  peculiar  to  our  author,  and  as  they  have  been,  and 
no  doubt  will  be,  contested,  we  direct  the  reader's  attention  to  the  evidence 
in  their  favor,  and  the  mode  of  reasoning  adopted. —  Cowan. 


Chap.  4.]  LYMPHATIC    GLANDS,    TUBERCULOUS.  99 

IN    PATIENTS     WHO     DIED    OF     OTHER    CHRONIC    DISEASES. 

145.  With  the  exception  of  the  tuberculous  granulations, 
we  have  met,  though  in  different  proportions,  all  the  other 
alterations  just  described,  in  cases  fatal  from  a  variety  of  other 
chronic  diseases.  Thus  out  of  ninety-two  individuals,  thirteen 
offered  a  greater  or  less  number  of  ulcerations,  confined  to  one 
or  n)ore  portions  of  the  large  intestine.  But  six  among  these 
had  tubercles  in  the  lungs,  and  were  consequently  phthisical  ; 
reducing  the  number  of  cases  with  ulcerations  to  seven  out  of 
eighty-six.  Of  these  seven,  four  were  examples  of  dysentery 
and  in  nearly  all  the  ulcerations  were  of  small  extent,  and 
slightly  varying  in  character  from  those  we  have  just  described. 
Softening,  with  or  without  redness  or  thickening  of  the 
mucous  membrane,  was  observed  in  one  third  of  the  cases, 
that  isj  much  less  frequently  than  in  phthisis. 


CHAPTER    IV. 


LYMPHATIC  GLANDS. 


146.  These  were  frequently  tuberculous,  sometimes  more 
or  less  red  and  increased  in  volume,  very  rarely  with  any  other 
kind  of  alteration.  The  relative  frequency  of  their  tubercu- 
lisation  was  as  follows  :  the  mesenteric,  meso-cœcal,  meso- 
colic,  cervical,  lumbar  and  axillary  glands.  We  do  not  enu- 
merate the  bronchial  glands,  for  although  we  examined  them 
with  equal  care,  we  have  most  frequently  omitted  to  note  the 
results.     We  think,  however,  that  we  may  venture  to  affirm,  on 


100      PATHOLOGICAL  ANATOMY. GLANDS  J       [Pai't  1, 

the  strength  of  later  observations,  that    they  are   not    oftener 
tuberculous  than  those  of  the  mesentery. 


ARTICLE    I 


MESENTERIC  GLANDS. 


147.  Out  of  one  hundred  and  two  cases,  where  they 
were  carefully  examined,  they  were  tuberculated  in  twenty- 
three.  Thus  modified,  their  volume  was  increased.  In  the 
majority  of  instances  the  transformation  was  not  general  ; 
it  was  only  partial  (Obs.  9,  15,  16,  31).  In  others,  only 
minute  points,  either  in  the  centre  or  circumference  of  the 
gland,  could  be  detected.  These  points  were  interspersed 
through  a  structure  usually  red,  and  less  consistent  than  nat- 
ural ;  in  general  the  altered  glands  were  aggregated  in  dis- 
tinct groups. 

All  the  mesenteric  glands  were  not  equally  affected.  Those 
nearest  the  caecum  were  most  frequently  modified  ;  and  in  the 
twenty-three  cases  we  are  now  examining,  we  have  only  once 
seen  the  affection  universal — (Obs.  23).  The  transformation 
of  each  individual  gland  was  here  complete  ;  no  trace  of  its 
primitive  structure  remaining. 

There  was  evidently  not  only  production  of  a  new  tissue, 
but  transformation  of  one  structure  into  another  ;  unless  we 
would  rather  admit  that  the  glandular  tissue  was  removed  in 
part  at  least  by  absorption.* 

148.  We  have  only  once  found,  in  the  centre  of  an  incom- 

*  The  transformation  of  healthy  into  morbid  structure  cannot  we  think  he 
satisfactorily  demonstrated  by  a  single  example.  In  physiology  the  gradual 
formation  of  our  tissues  follows  certain  laws,  and  has  certain  limits  —  but 
morbid  deposit  seems  always  something  more  —  something  added,  and  not 
merely  a  modification  of  what  previously  existed.     If  we   might  cite   our 


#^ 


Chap.  4.]      MESENTERIC,  TUBERCULOUS.  101 

pletely  tuberculated  mesenteric  gland,  a  small  portion  of  the 
grey  semi-transparent  substance.  In  all  other  cases,  the  gra- 
nulation was  yellowish,  opaque,  and  really  tuberculous  from 
the  first  moment  it  could  be  observed.  This  mode  of  devel- 
opment of  the  tuberculous  matter  differs  from  what  Laennec 
^considers  to  be  the  case  in  the  lungs. 

149.  The  mesenteric  glands,  when  tuberculated,  presented 
10  other  organic  alteration.     We  have   only  once  remarked, 

^conjoined  with  tuberculous   matter,  a  shining;  firm,  granulous 
substance,  very  analogous  to  encephaloid  matter — (Obs.  4).* 

150.  The  mesenteric  tubercles  were  very  rarely  softened  ; 
result  no  doubt   depending  on  their  being    recent.     This   is 

[t  least  probable,  for,  in  the  majority  of  cases,  the  development 
of  tuberculous  matter  in  the  mesenteric  glands  seems  gradual, 
^and  is  almost  always  partial  j  it  is  consequently  recent  at  the 

own  observations,  we  would  say  that,  nowhere  is  this  more  evident  than 
in  the  lymphatic  glands,  which  often  combine  the  e,reat  advantage  of  pre- 
senting an  identical  alteration  in  all  its  various  stages  ;  and  from  a  careful 
inspection  of  cases  where  this  facility  was  afforded,  the  tuberculous  matter 
seemed  always  a  simple  deposit,  and  by  its  gradual  increase,  to  have  caused 
the  ultimate  absorption  of  the  glandular  structure. —  Cowan. 

**Thc  co-existence  oil  different  morbid  alterations  is  a  subject  of  considera- 
ble pathological  importance.  Pathologists  are  well  aware  that  tumors, 
wherever  situated  in  the  body,  are  almost  invariably  of  the  same  description, 
and  knowing  the  nature  of  one,  they  do  not  hesitate  to  predict  that  of  the 
others.  There  is  a  remarkable  case  cited  by  Andral  (Anat.  Path.  vol.  i.  p. 
420),  showing  the  great  analogy  of  cancerous  and  tuberculous  matter. 
Trousseau  {Arch- Gen.  de  Med.,  1823)  has  found,  though  very  rarely,  these 
two  morbid  productions  together,  as  well  as  cancer  and  melanosis.  We  have 
already  seen  that  extreme  emaciation  characterises  both  the  cancerous  and 
tubercular  diathesis,  and  this  unity  of  effect  under  such  different  circumstan- 
ces, with  respect  to  the  pulmonary  oigans,  induces  us  to  suppose  that  loss 
of  flesh  in  phthisis  may  not  be  a  consequence  of  the  condition  of  the  lungs. 

—  CoWAN. 


102  PATHOLOGICAL  ANATOMY.  GLANDS  ;  [Part  I, 

period  of  the  individual's  death,  and    the  softening  only  takes 
place  when  the  transformation  is  complete. 

151.  But  what  is  the  cause  of  this   alteration  ?      We  have 
remarked  (147)  that  the  mesenteric  glands  when  tuberculous 
were    increased    in  volume  :  when  they  only  presented  some       '"^ 
tuberculous  points,  they  were  more  or  less  of  a  bright  red  and 
often  slightly  softened.     But  this  slight  excess  of  volume  was. 
not  always  accompanied  with  this  change  of  color  and   consis-  / 
tence  ;  so  that  in  some  instances  inflammation  appears  to  have    f 
influenced    the  development   of  tuberculous   matter,  while  in"'  j 
others,  and  in  not  so  large  a  number   of  cases,  it  is   true,  no  -' 
such  influence  can  be  traced.  -  M     -^ 

Whatever  may  be  the  immediate  cause  of  these  tubercles,  '"". 
let  us  now  inquire  whether  they  invariably  depend  on  an  in- 
flammatory state  of  the  corresponding  mucous  membrane  ?  J 
In  every  instance,  when  the  mesenteric  glands  were  tubercu-  j 
lous,  we  have  found  ulcerations  of  the  small  intestine,  and  these 
ulcerations  had  not  taken  place  without  primary  or  secondary 
inflammation  of  the  mucous  membrane  ;  they  were  also  them- 
selves a  perpetual  source  of  irritation.  When  the  mesentery 
was  only  partially  tuberculated,  it  was  so  in  the  cajcal  portion, 
or  the  part  which  corresponds  to  the  most  usual  seat  of  large 
ulcerations.  Tliese  facts  seem  to  point  out  a  close  connexion 
between  tubercles  in  the  mesentery,  the  mucous  membrane, 
and  ulcerations  of  the  small  intestine  5  but  in  more  than  one- 
half  of  the  cases,  the  ulcerations  were  small,  and  when  ex- 
tensive, and  consequently  chronic,  no  increase  of  tuberculous 
matter  was  observed.  The  only  example  of  complete  tuber- 
culous transformation  of  a// the  mesenteric  glands  was  that  of 
a  young  man,  whose  affection  was  still  recent,  who  had  expe- 
rienced but  very  sliglit  diarrliœa,  and  in  whom  we  found  the 
mucous  membrane  of  the  small  intestine  perfectly  healthy,  both 


/ 


Chap.  4.]  MESENTERIC,    TUBERCULOUS.  103 

as  regards  color,  consistence,  and  thickness. — (Obs.  23.)  The 
only  appreciable  alteration,  and  doubtless  it  is  not  a  very  im- 
portant one  with  regard  to  the  object  we  have  in  view,  was  a 
round  ulceration  of  a  line  in  diameter,  with  pale  flat  edges, 
situated  near  the  caecum.  We  must  therefore  conclude,  that 
if  the  inflammation  of  the  lymphatic  glands,  that  of  the 
mucous  membrane,  and  the  ulcerations  of  the  small  intestine, 
ought  to  be  viewed  as  the  occasional  cause  of  mesenteric 
tubercles,  there  are  other  cases  where  no  such  dependence 
exists.  It  may  perhaps  be  said  in  reply  to  this,  that  tubercu- 
lous affections  are  essentially  chronic,  and  probably,  that  of  the 
mesentery  existed  anteriorly  to  the  origin  of  the  principal 
disease,  and  that  during  this  interval  the  inflammation  of  the 
raucous  membrane  might  have  disappeared.  But  this  is  only 
opposing  an  hypothesis  to  a  fact,  and  taking  for  granted  as  an 
invariable  law,  what  really  is  not  so  ;  for,  tuberculous  matter 
is  capable  of  very  rapid  development,  as  we  shall  hereafter 
prove,  when  speaking  of  the  progress  of  phthisis.  We  may 
remark  in  anticipation,  that  we  have  never  met  mesenteric 
tubercles  except  in  phthisical  cases  ;  we  cannot  therefore 
suppose  them  to  have  preceded  the  principal  affection;  partic- 
ularly as  no  well  marked  indications  of  irritation  of  the 
mucous  membrane  of  the  small  intestine  were  at  any  time  ob- 
served.* 

152.  The  duration  of  phthisis  had  no  influence  on  the  de- 
velopment of  the  modiflcation  we  are  now  considering.  It 
was   equally  frequent  in  cases  where  the   disease  was  recent, 

*  The  mode  of  reasoning  to  which  our  author  resorts  is  rather  novel  in 
medicine,  and  indeed  till  very  lately  would  have  been  impossible.  The 
reader  will  observe  how  it  wholly  rests  on  numerical  facts,  and  to  what  sat- 
isfactory conclusions  it  would  often  lead,  and  what  useless  conjectures  would 
be  avoided,  were  accurately  analysed  facts  at  our  disposal.  —  Cowan. 


104  PATHOLOGICAL    ANATOMY.  GLANDS;  [Parti, 

(from  six  weeks  to   five  months,)  as  when  it   was  protracted 
from  one  to  ten  years. 

153.  When  the  glands  were  not  tuberculous,  they  were 
quite  often  greatly  increased  in  volume,  and  of  a  variably  in- 
tense red  color.  This  may  lead  us  to  conclude,  that  when  the 
tuberculous  matter  was  coincident  with  inflammation,  it  had 
been  preceded  by  the  latter. 

154.  We  have  not  detected  any  symptom  which  could  be 
attributed  to  the  alteration  before  us.  In  the  instance  already 
cited,  where  the  whole  of  the  mesenteric  glands  were  tuber- 
culated,  the  patient  never  complained  of  pain  around  the  um- 
bilicus. Pressure  properly  applied  discovered  no  tumor. 
However,  if  in  cases  of  phthisis,  we  detected  a  tumor  in  the 
region  of  the  mesentery,  it  might,  we  think,  be  regarded  as 
tubercidous,  for  in  no  example  of  this  description  have  we 
observed  any  other. 


ARTICLE   II. 

MESO-CiECAL,  MESO-COLtC,  AND  LUMBAR  GLANDS. 

155.  The  raeso-csecal  glands  were  rather  less  frequently 
tuberculated  tlian  those  of  the  mesentery,  but  oftener  than 
those  of  the  right  lumbar  meso-colon.  They  were  enlarged 
like  tlie  mesenteric  glands,  seldom  entirely  transformed 
into  tuberculous  matter,  and  were  more  or  less  red  in  points 
where  this  transformation  did  not  extend. 

Five  times  out  of  sixty  the  lumbar  glands  have  been  tuber- 
culated. In  three  cases  their  transformation  was  complete  ; 
they  were  about  the  size  of  a  walnut,  indurated,  and  nowhere 
softened  in  the  least  degree.     In  one  of  these  cases   the  mu- 


Chap.  4.]       MESO-C^C AL,  CERVICAL,  AXILLARY,  &,C.  105 

COUS  membrane  of  the  small  intestine  and  colon  was  perfectly 
healthy,  and  the  state  of  the  glands  could  not  be  explained  by 
any  lesion  of  the  abdominal  viscera.  The  patient  was  a  female 
of  seventy  years  old. 

In  not  one  of  the  cases  now  under  consideration,  have  we 
seen  the  grey  semù-transparent  matter  combined  with  the  tu- 
berculous ;  the  development  of  the  latter  therefore  follows  the 
same  course  as  in  the  mesenteric  glands.  We  have  only  once 
found  the  right  lumbar  meso-colic  glands  tuberculated. 


ARTICLE   III. 

CERVICAL,   AXILLARY,  AND  BRONCHIAL  GLANDS. 

156.  The  cervical  glands  were  more  or  less  tuberculous  in 
one-tenth  of  our  cases,  eight  times  out  of  eighty  ;  and,  like  the 
mesenteric  glands,  larger  than  natural,  and  of  a  variably  in- 
tense red  color  in  the  parts  which  had  not  undergone  tuber- 
culisation  (Obs.  9,  18,  35,  47).  In  four  of  these  cases, 
the  mucous  membrane  of  the  trachea  was  of  a  more  or  less 
florid  red  color.  In  one  instance  it  even  presented  some  small 
ulcerations.  In  the  others,  it  was  healthy  ;  so  that,  in  not  one 
of  the  examples  presenting  those  vast  ulcerations  we  have 
described  (Obs.  15,  43),  were  the  cervical  glands  tubercu- 
lated  ;  and  here,  as  in  many  cases  of  mesenteric  tubercles,  tu- 
berculous transformation  must  be  viewed  as  depending  on 
some  other  cause  than  the  inflammation  of  the  corresponding 
mucous  membrane. 

In  a  single  instance  (Obs.  9),  the  cervical  glands,  converted 
into  tuberculous  matter,  were  the  cause  of  pain,  and  this  pa- 

N 


106  PATHOLOGICAL  ANATOMY.  GLANDS.  [Parti, 

tient  also  furnished  the  only  example  we  possess  of  tubercles 
in  the  axillary  glands,  and  the  same  pain  was  also  complained 
of  in  the  latter  as  in  the  neck. 

157.  When  the  bronchial  glands  were  tuberculous,  they 
were  usually  of  increased  volume,  and  of  a  grey  and  blackish 
color.  They  were  very  rarely  tinged  with  red,  or  with  an 
onion-peel  color. 

IN    PATIENTS     WHO    DIED    OF     OTHER    CHRONIC    DISEASES. 

158.  The  morbid  change  we  are  examining  seems  peculiar 
to  phthisis.  In  ninety-eight  cases,  fatal  from  a  variety  of 
chronic  diseases,  as  dysentery,  &£C.  &;c.  we  have  not  met  a 
single  instance  of  tuberculated  lymphatic  glands.  A  consid- 
erable number,  however,  among  them,  were  examples  of  in- 
flammation and  sometimes  ulceration,  he.  of  the  intestinal 
mucous  membrane;  an  additional  motive  for  believing  that  the 
inflammation  of  mucous  membranes  is  not  either  the  only 
cause,  or  even  the  most  important  element  of  tuberculous 
transformation.* 

*  M.  Broussais  says,  he  has  often  found  them,  (tuberculated  glands)  inde- 
pendently of  any  tubei'culous  affection  of  the  lungs,  both  in  adults  and  in- 
fants. Vide  Exam.  Med.  vo\.  i.  p.  344.  To  judge  of  the  value  of  this 
assertion,  we  i-efer  the  reader  to  what  our  author  has  stated  in  page  19,  of 
his  reply  to  M.  B.'s  criticisms.  M.  L.  fully  confirms  the  accuracy  of  the 
opinion,  that  after  tlie  age  of  fifteen,  tuberculated  glands  never  exist  without 
tubercles  in  the  lungs,  by  the  additional  experience  of  eight  years.  — 
Cowan. 


Chap.  5.]  LIVER  ;  fatty  state.  107 


CHAPTER    V. 


BILIARY  APPARATUS. 


ARTICLE    I, 


LIVER. 


159.  The  fatty  transformation  of  the  liver  was  the  most  fre- 
quent, and  at  the  same  time  the  most  remarkable  alteration  of 
this  organ,  it  existed  in  one-third  of  the  cases  (forty  out  of 
one  hundred  and  twenty).  In  this  condition  the  liver  was  pale, 
almost  always  of  a  light  brownish  yellow  color,  spotted  with 
red,  externally  and  internally.  It  retained  its  natural  form  ;  but 
its  volume  was  nearly  always  augmented,  and  at  times  double  its 
usual  dimensions.  This  increase  was  almost  invariably  at  the 
expense  of  the  right  lobe.  The  liver  then  overlapped  a  large 
portion  of  the  anterior  surface  of  the  stomach,  occupied  the  epi- 
gastrium, extended  the  breadth  of  two  or  three  fingers  below  the 
false  ribs,  and  reached  the  iliac  crest  and  the  spleen,  which 
was  also  occasionally  covered.  We  once  saw  it  situated  in 
the  centre  of  the  abdomen,  and  about  two  inches  from  the 
pubes. 

160.  Its  consistence  (with  the  exception  of  cases  where  the 
alteration  was  but  slightly  pronounced)  was  greatly  dimin- 
ished; it  easily  yielded  to  traction,  and  was  sometimes  much 
softened.  In  very  advanced  cases,  the  scalpel  and  hands  were 
greasedas  by  ordinary  fat   substances.       When   the  morbid 


108  PATHOLOGICAL    ANATOMT. LIVER;  [Parti, 

change  was  much  less  evident,  we  ascertained  its  exist- 
ence by  placing  a  thin  section  of  the  liver  on  a  sheet  of 
paper;  and  exposing  it  to  the  flame  of  a  candle  :  a  very 
slight  heat  melted  a  small  quantity  of  the  fat,  saturated  the 
paper,  and  thus  demonstrated  its  presence.  The  lesion  con- 
stantly occupied  the  whole  of  the  liver.* 

161.  The  causes  of  the  fatty  transformation  of  the  liver 
appear  to  us  equally  obscure  as  those  of  other  organic  diseases. 
Without  therefore  attempting  any  explanation,  we  will  point 
out  the  principal  circumstances  with  which  it   is  accompanied. 

One  of  the  most  obvious  is,  that  this  lesion  is  almost  con- 
fined to  cases  of  phthisis  ;f  so  that  it  may,  to  a  certain  point, 
be  considered  as  depending  on  this  affection.  Out  of  two  hun- 
dred and  thirty  cases,  nearly  equally  divided  between  acute  and 
chronic  diseases,  we  have  only  met  nine  examples  of  fatty  liver, 
and  among  these  nine,  seven  relate  to  patients  who  presented  a 
certain  number  of  pulmonary  tubercles.  By  adding  these 
nine  cases  to  the  forty  already  mentioned,  we  have  forty-nine 

*  The  fact  of  any  particular  morbid  alteration,  invariably  occupying  the 
totality  of  the  organ  affected,  is  interesting,  and,  combined  with  the  gene- 
ral characters  of  inflammation  when  attacking  parenchymatous  organs,  viz. 
that  of  being  usually  bounded  to  one  side  of  the  body,  if  the  organ  is  double, 
and  almost  invariably  (perhaps  always)  to  a  greater  or  less  portion  of  or- 
gans, which  are  single,  we  may,  I  think,  justly  entertain  a  doubt  as  to  its 
inflammatory  origin.  This  observation  is  applicable  to  that  state  of  the  kid- 
ney, so  accurately  described  by  Dr.  Bright.  Other  reasons  we  think  might 
also  be  adduced  in  favor  of  the  idea  that  it  does  not  arise  from  inflammation. 
—  Cowan. 

f  Compare  this  with  the  150th  proposition  of  M.  Broussais  :  —  "  Chronic 
gastro-enteritis  is  the  cattse  of  hepatic  engorgements,  and  of  those  yellow  fatty 
enlargements  of  the  liver,  which  we  sometimes  find  in  the  bodies  of  those 
who  die  even  of  phthisis  .'"  —  Andral  has  arrived  at  the  same  results  as  M. 
Louis.  —  Cowan. 


Chap.  5.]        FATTY  STATE CAUSES.  109 

examples  of  this  condition  of  the  liver  (and  these  include  all 
we  have  collected  during  three  years),  out  of  which  forty- 
seven  were  cases  of  phthisis.  There  are  assuredly  few  phe- 
nomena of  whose  mutual  dependence  there  is  no  doubt, 
in  confirmation  of  which  facts  are  more  unanimous. 

Sex  is  another  cause  which  favors  the  fatty  degeneration  of 
the  liver  ;  for,  out  of  the  forty-nine  cases  above  mentioned, 
ten  only  relate  to  men,  —  leaving  the  proportion  between 
them  and  female  patients,  nearly  as  one  to  four.  It  is  true 
that  phthisis  was  rather  more  frequent  among  the  latter,  in  the 
ratio  of  sixty-six  to  fifty-seven  ;  but  this  difference  cannot  sen- 
sibly affect  our  calculation,  or  the  accuracy  of  our  assertion. 

The  strength  or  weakness  of  the  constitution  exercised  no 
influence  in  producing  the  alteration  in  question.  Age  was 
equally  without  effect.  Among  the  forty  phthisical  cases  re- 
ferred to,  eighteen  were  from  twenty  to  thirty,  thirteen  from 
thirty  to  forty,  five  from  forty  to  fifty,  three  from  fifty  to  sixty, 
and  one  from  sixty  to  seventy  ;  a  proportion  almost  coinciding 
with  the  frequency  of  phthisis  in  the  different  periods  of  hfe. 

We  are  also  unable  to  enumerate  among  the  number  of 
causes,  which  favor  the  development  of  this  fatty  state  of  the 
liver,  the  diseases  of  the  duodenum  ;  since,  in  the  first  place, 
these  were  rare,  and  equally  so  in  cases  where  the  liver  pre- 
sented the  fatty  transformation,  as  in  those  where  it  was  per- 
fectly healthy  (102.) 

162.  This  morbid  alteration  may  take  place  very  rapidly. 
We  have  seen  it  in  instances  where  phthisis  had  passed  through 
all  its  stages  in  fifty  days  (Obs.  36.) 

The  variations  in  the  duration  of  the  disease  have  not  sen- 
sibly modified  the  proportion.  The  results  were  similar  in 
cases  where  phthisis  had  lasted  only  some  months,  or  had 
been  protracted  during  several  years. 


no  PATHOLOGICAL    ANATOMY.  —  LIVER  ;  [Part  I> 

163.  If,  however,  we  admit  that  this  peculiar  condition  of 
the  liver  niay  be  acute  or  chronic,  our  conclusion  can  only  be 
founded  on  the  dependence  existing  between  this  lesion  and 
phthisis  itself;  for  we  have  no  means  of  diagnosis  in  our  power 
at  any  period  of  its  duration.  We  have  in  vain  attempted  to 
assign  to  it  any  class  of  symptoms  ;  none  such  presented  them- 
selves. There  was  no  pain  complained  of  in  the  right  hypo- 
chondrium  ;  pressure  on  the  liver,  when  extending  below  the 
edges  of  the  false  ribs,  was  equally  without  effect  ;  and  if  it 
caused  pain  in  the  epigastrium,  when  occupied  by  the  liver, 
this  might  be  attributed  to  the  state  of  the  gastric  mucous 
membrane.  We  have  only  once  seen  the  color  of  the  skin 
affected  ;  this  was  in  the  case  of  a  female  patient,  aged  30 
(Obs.  30),  in  whom  phthisis  was  both  very  obscure  and  slow 
in  its  progress.  She  had  lived  in  England  some  years,  and 
about  the  middle  period  of  the  disease,  had  experienced  some 
shooting  pricking  pains  in  the  right  hypochondrium,  and  other 
symptoms  which  induced  a  suspicion  of  disease  of  the  liver. 
She  was  treated  with  purgatives  and  calomel.  The  color  of 
the  skin  became  gradually  changed,  and  when  we  saw  the  pa- 
tient, it  presented  a  very  pale  yellow  tint,  except  on  the  face, 
where  it  inclined  more  to  a  brown  and  was  less  equally  distrib- 
uted. The  sclerotics  retained  their  natural  white  color  ;  and 
this  fact,  as  we  shall  hereafter  see,  ought  necessarily  to  throw 
a  doubt  over  the  presumed  cause  of  the  color  of  the  skin. 

In  this  absence  of  all  characteristic  symptoms,  there  is  only 
one  circumstance  which  might  lead  us  to  suspect  the  patholo- 
gical condition  of  the  liver  ;  viz.  its  increased  volume,  which 
exists  frequently  and  almost  exclusively  in  phthisis  in  such 
cases. 

1C4.  In  every  case  where  the  adipous  degeneration  existed, 
the  liver  presented  no  other  organic  lesions.      The  latter,  in- 


Chap.  5.]  CYSTS,     FRIABILITY,     EMPHYSEMA.  Ill 

deed,  were  at  all  times  very  rare.  Thus  we  have  only  twice 
remarked  tuberculous  matter  in  this  organ  (Obs.  9).  In 
two  individuals,  from  eighteen  to  nineteen  years  old,  this  organ 
offered  internally  numerous  small  cysts,  from  one  to  three  lines 
in  diameter,  of  slight  consistence,  barely  allowing  them  to  be 
separated  from  the  surrounding  tissue.  Their  parietes  were 
about  the  twenty-fifth  part  of  an  inch  thick,  and  enclosed  a 
greenish  pulpy  substance.  We  have  only  encountered  these 
cysts  in  the  liver  and  in  cases  of  phthisis. 

In  another  instance  (a  woman  aged  twenty-nine),  the  middle 
lobe  was  destroyed  and  replaced  by  an  irregularly  rounded 
fibrous  cyst,  nearly  double  in  volume  the  lobe  to  which  it  corres- 
ponded, and  of  the  25th  of  an  inch,  or  often  less,  in  thickness. 
This  cyst,  of  a  yellowish  white,  contained  a  colorless  rather  tur- 
bid fluid,  of  moderate  density,  in  which  floated  about  one  hun- 
dred minute  rounded  bodies,  varying  from  the  size  of  hemp-seed 
to  that  of  a  small  cherry.  They  were  formed  by  a  thin  mem- 
brane, enclosing  a  limpid  fluid.  The  parietes  of  the  cyst  itself 
were  composed  of  a  white  opaque  membrane,  of  the  consis- 
tence of  coagulated  albumen,  from  half  a  line  to  three  quarters 
of  a  line  thick,  very  slightly  adherent,  smooth  and  polished 
like  a  serous  membrane  on  its  outer  surface,  and  of  a  dull  ap- 
pearance internally.  Here  also  there  were  five  elongated  ele- 
vations, from  an  inch  to  an  inch  and  a  half  of  surface,  and 
from  one  to  two  lines  thick,  rough,  nodulated,  and  presenting 
the  aspect  of  the  concrete  albumen  on  the  surface  of  a  poached 
egg.     The  parenchyma  surrounding  the  cyst  was  healthy. 

The  consistence  of  the  liver  was  very  variable,  sometimes 
soft,  at  other  times  firmer  than  natural,  often  combining  indu- 
ration with  brittleness,  but  in  no  instance  giving  rise  to  any 
characteristic  symptoms.  One  of  the  patients,  whose  history 
we  have  given  (Obs.  7),  presented  a  solitary  example  of  an 


112  PATHOLOGICAL  ANATOMY.  BILE.  [Part  I, 

emphysematous  liver  ;  it  was  lighter  than  the  lungs,  and  rather 
-less  than  its  natural  volume. 


ARTICLE     II. 

BILE    AND    GALL    BLADDER. 

165.  In  one-third  of  the  cases  where  liver  was  adipous,  the 
bile  in  the  gall  bladder  was  very  dark  colored,  of  a  viscid  trea- 
cle-like consistence,  in  a  medium  state,  as  it  were  between  a 
solid  and  fluid.  In  another  third,  it  was  still  very  thick,  but 
less  so  than  what  we  have  just  described.  In  the  last  division, 
its  color  and  consistence  were  natural,  and  in  general  it  was 
less  abundant  according  as  it  was  more  viscid.* 

However,  the  thickened  state  of  the  bile,  in  which  it  as- 
sumes very  much  the  appearance  of  treacle,  is  not  confined 
to  this  particular  modification  of  the  liver.  We  find  it  in  other 
conditions  of  this  organ,  though  proportionably  it  is  much  less 
frequent.  Thus,  in  three  phthisical  patients,  where  the  liver 
was  healthy,  the  bile  presented  this  peculiar  consistence.  We 
have  observed  the  same  fact  in  patients  who  died  from  other 
chronic  diseases,  and  whose  liver  was  healthy.  In  five  out 
of  seventy,  the  bile  had  a  semi-solid  consistence  similar  to 
that  of  treacle. 

166.  No  relation  could  be  traced  between  the  state  of  the 
bile  and  that  of  the  stomach.     Its  consistence  was  very  con- 

*  The  healthy  state  of  tlie  secretion,  in  a  large  proportion  of  the  cases, 
and  its  similarity  with  that  observed  in  other  instances  where  the  hepatic 
parenchyma  appeared  sound  while  the  secretion  itself  varied  are  additional 
arguments  in  support  of  the  opinion  we  have  advanced  in  a  previous  note, 
that  the  peculiar  modification  in  question  is  not  depending  on  inflammation. 
—  Cowan. 


Chap.   5.]        GALL-BLADDKR  ;    CONSISTENCE,  &;C.  113 

siderable  under  the  most  varied  conditions  of  the  latter  ;  when 
the  mucous  membrane  of  the  stomach  was  softened,  thinned, 
inflamed,  or  perfectly  healthy  ;  when  patients  had  partially 
preserved  their  appetite  to  the  last,  or  when  anorexia  was  com- 
plete long  before  death  ;*  both  when  vomiting  had  been  fre- 
quent, and  when  it  was  altogether  absent.  In  no  instance 
have  we  detected  any  appreciable  change  in  the  bile  of  the 
ductus  choledocus. 

167.  The  parietes  of  the  gall-bladder  were  seldom  mor- 
bidly affected.  Twice  we  have  seen  them  more  or  less  thick- 
ened from  infiltration,  and  twice  from  another  cause.  In  one 
of  these  last  (Obs.  49),  adhesions  were  formed  between  the 
fundus  of  the  gall-bladder  and  the  abdominal  parietes,  and  in 
the  corresponding  point  its  mucous  membrane  was  destroyed 
to  the  extent  of  about  an  inch.  Similar,  though  less  consider- 
able, loss  of  substance  existed  near  the  neck.  Elsewhere  the 
membrane  was  about  a  quarter  of  a  line  thick,  and  presented 
in  miniature  the  columnated  appearance  sometimes  seen  in 
the  urinary  bladder.  The  submucous  cellular  tissue  was 
thickened,  and  the  portions  corresponding  to  the  ulcerations 
easily  torn.  The  gall-bladder  contained  about  two  hundred 
calculi,  varying  in  volume  from  that  of  a  pea  to  a  millet-seed. 
Two  years  before  her  death  the  patient  had  experienced  acute 
pains  in  the  corresponding  region  of  the  abdomen,  and  during 
eleven  months  had  had  several  attacks  of  jaundice.  In  three 
women,  of  the  respective  ages  of  thirty,  thirty-four  and  sixty, 

*  In  the  original  are  the  words  "  bien  avant  le  terme  total."  They  seem 
to  have  escaped  the  notice  of  the  translator.  I  presume  there  is  a  verbal 
error  in  the  original,  and  that  "  total"  should  be  "fatal"  and,  therefore,  I 
have  translated  them  as  above.  —  H.  I.  B. 


114  PATHOLOGICAL    ANATOMY. SPLEEN,  [Part  I, 

a  considerable  number  of  calculi  were  found  immersed  in  a 
large  quantity  of  bile,  without  any  alteration  of  the  parietes  of 
the  gall-bladder.  No  symptom  indicated  their  presence,  and 
deatb  took  place  at  different  periods  of  the  year,  spring,  sum- 
mer and  autumn. 

IN    PATIENTS     WHO    DIED     OF     OTHER    CHRONIC    DISEASES. 

16S.  In  cases  fatal  from  various  chronic  affections,  princi- 
pally of  the  liver  (perhaps  chronic  hepatitis),  we  have  also 
found  biliary  calculi,  with  thickening  and  ulceration  of  the  coats 
of  the  gall-bladder.  These  alterations  were  even  a  little 
more  frequent  in  these  diseases  than  in  phthisis.  The  biliary 
calculi  were  not  constantly  accompanied  by  ulcerations,  but  we 
have  never  observed  the  latter  when  the  former  were  not  pres- 
ent in  larger  or  smaller  quantities.  Calculi  were  also  generally 
present  when  the  mucous  membrane  was  simply  thickened. 


CHAPTER   VI. 


SPLEEN. 

169.  If  our  ignorance  of  the  functions  of  the  spleen  renders 
the  study  of  its  morbid  changes  less  interesting  than  that  of  those 
of  other  organs,  their  number  and  frequency  are  at  least  calcu- 
lated to  excite  the  zeal  of  observers  ;  and,  on  this  account,  we 
cannot  but  enumerate  the  results  of  our  examination.  The 
alterations  observed,  referred  in  general  to  its  consistence  and 
volume,  or  the  development  of  accidental  tissues. 


Chap.  6,]  tuberculous;  size.  115 

170.  The  latter  were  two  in  number  :  one,  the  tuberculous, 
which  existed  in  one  fourteenth  of  the  cases  ;  viz.,  seven 
times  out  of  ninety  instances,  which  were  carefully  examined 
(Obs.  6,  7,  9).  The  tubercles  were  very  numerous,  varying 
in  volume  between  a  hemp-seed  and  that  of  a  filbert  in  one 
case.  They  were  in  all,  with  one  exception,  more  or  less 
round,  yellowish,  opaque,  of  a  dull  appearance,  in  allrespects 
similar  to  those  in  the  lungs.  They  were  not  encysted,  and 
the  immediately  surrounding  tissue  was  healthy.  In  two 
patients,  where  they  were  the  most  numerous,  various  other 
parts  of  the  body  were  affected,  as  the  mesentery,  neck,  axilla, 
and  even  the  brain  (Obs.  9).*  We  have  never  observed  the 
grey,  semi-transparent  matter  conjointly  with  tubercles  ;  so 
that  here  again  they  appear  to  be  tuberculous  from  the  com- 
mencement. In  the  seventh  observation  the  tuberculous 
matter  had  not  its  usually  rounded  appearance,  and  in  other 
respects  presented  slight  variations  from  what  was  observed  in 
the  others.  The  individual  was  a  man,  aged  thirty-seven, 
whose  disease  had  lasted  five  months,  and  in  whom  the  spleen 
presented  rather  an  increased  volume  ;  it  was  partially  ad- 
hering to  the  diaphragm,  and  wholly  covered  by  a  false, 
cartilaginous  membrane,  about  a  half  a  line  thick.  Beneath 
it,  on  the  outer  surface  of  the  spleen,  was  a  dull  yellow-colored 
tissue,  not  evidently  organised,   very  firm  and  resisting,  very 

*  The  result  of  our  own  observations,  from  a  residence  of  eight  months  in 
the  Hôpital  des  Enfans  Malades,  at  Paris,  would  lead  us  to  suspect  that 
the  proportional  frequency  of  tubercles  in  the  different  organs  varied  much 
in  the  infant  and  adult.  The  brain  especially  presented  them  much  more 
frequently  ;  and  when  this  was  the  case,  with  very  few  exceptions,  we 
found  tubercles  in  the  spleen.  Exact  knowledge  of  the  changes  in  the  seat 
and  characters  of  disease  in  different  periods  of  life  is  an  interesting  and 
important  subject  for  future  researches.  —  Cowan. 


116  PATHOLOGICAL    ANATOMY. SPLEEN.       [Parti, 

similar  to  chamois  leather  ;  it  had  a  lenticular  conformation, 
four  inches  and  a  half  in  diameter,  being  thin  at  the  edges, 
and  about  one  inch  thick  in  the  centre. 

171.  The  other  description  of  morbid  structure  we  have 
only  met  once  ;  it  consisted  of  rounded,  yellowish,  shining, 
elastic,  moist  granulations,  very  different  from  tubercle,  and 
irregularly  interspersed  through  the  parenchyma  of  a  softened 
and  enlarged  spleen. 

172.  The  volume  of  this  organ  was  very  variable  ;  much 
smaller  than  natural  in  fifteen  individuals,  while  it  was  twice, 
three,  four,  or  more  times  its  usual  size  in  sixteen  others.  We 
have  endeavored  to  discover  whether  there  was  any  relation 
between  this  increased  volume  and  intermittent  or  continued 
fevers  experienced  by  the  patient  at  a  period  more  or  less 
anterior  to  death,  and  we  arrived  at  a  negative  result.  In 
the  majority  of  individuals  who  had  had  intermittent  or  severe 
continued  fever,  this  organ  was  very  small  ;  we  have  only 
twice  found  it  voluminous  after  the  former,  and  once  after  the 
latter. 

173.  Its  consistence  was  as  variable  as  its  size.  In  ten 
cases  it  was  much  firmer  than  usual,  and  in  all,  with  one  ex- 
ception, the  ivhole  of  the  parenchyma  was  equally  affected. 
Increased  density  was  most  frequently  connected  with  increas- 
ed volume.  This  was  also  sometimes  combined  with  great 
friability.  In  eight  out  of  ninety  cases,  the  softening  was  equal 
to  or  even  greater  than  that  in  typhus  fever. 

IN  PATIENTS     WHO    DIED    OF     OTHER    ACUTE    OR    CHRONIC    DISEASES. 

174.  To  determine  whether  any  peculiar  influence  could 
be  ascribed  to  phthisis  in  the  production  of  these  various 
changes,  they  have  been  compared  with  analogous  states  in 
cases  fatal  from   various  acute  and  chronic  diseases.     In  the 


Chap.  7.]  URINARY  organs;  tubercles;  cysts.  117 

latter  the  increase  of  volume  was  in  the  same  proportion  as  in 
phthisis,  while  its  diminution  was  at  once  more  considerable 
and  more  ^frequent.  Out  of  one  hundred  and  sixty  cases 
where  we  are  not  including  examples  of  typhus,  in  fifty  the 
spleen  was  small.  Among  these,  the  decrease  was  very  con- 
siderable in  twenty-one  instances,  fatal  from  pneumonia,  or 
some  affection  of  the  heart  ;  a  result  seemingly  pointing  out 
that  the  dimensions  of  the  spleen  are  independent  of  embar- 
rassed cir'iulatlon.  Softening  was  more  frequent  after  acute 
than  after  chronic  diseases  ;  very  nearly  coinciding  with  the 
proportions  observed  in  phthisis.  In  none  of  these  examples 
have  we  seen  the  spleen  tuberculated. 


CHAPTER    VII. 


URINARY  ORGANS. 


175.  They  very  seldom  offered  any  remarkable  changes. 

We  have  frequently  attentively  examined  the  renal  cap- 
sules, and  the  only  alteration  observed  was,  in  two  instances, 
a  small  quantity  of  unsoftened,  tuberculous  matter.  We  have 
never  seen  the  latter  in  these  organs  in  cases  of  chronic  dis- 
ease, except  in  those  of  phthisis. 

176.  The  Tcidneys,  in  three  fourths  of  the  examples,  were 
perfectly  sound,  as  to  their  consistence,  color,  and  vol- 
ume. Sixteen  times  only  out  of  ninety  we  have  found  them 
rather  redder  than  natural.  Three  times  their  consistence  was 
considerably  increased.     In  four  cases,  small  cysts  were  de- 


118    PATHOLOGICAL  ANATOMY.  URINARY  ORGANS  ;    [Part  I, 

veloped  (Obs.  19).  In  three  they  presented  a  certain  quan- 
tity of  tuberculous  matter,  and  in  one  of  these  the  alterations 
extended  into  the  ureter.  The  great  rarity  of  similar  facts 
induces  us  to  give  the  history  of  the  instance  to  which  we 
have  alluded. 


FIFTH    OBSERVATION. 

A  BARBER,  set.  24,  of  a  scrofulous  and  delicate  habit, born  ol 
healthy  parents,  at  the  age  of  twelve  years  sprained  the  right 
foot.  After  the  persistence  of  acute  pains  during  two  years, 
they  ceased,  recurring  at  distant  intervals.  Some  fistulae, 
formed  round  the  tibio-tarsal  articulation,  discharged  during 
four  years  before  we  saw  him,  almost  constantly,  a  certain 
quantity  of  pus.  He  had  continued  his  business,  and  often 
walked  considerable  distances  without  inconvenience.  He  had 
coughed  and  expectorated  a  year  and  seven  months,  and  was 
admitted  into  the  hospital  of  La  Charité,  February  16th,  1822. 
At  the  commencement  of  the  cough,  some  very  acute  pains  in 
right  side  of  the  chest  compelled  the  application  of  a  large  num- 
ber of  leeches  to  the  spot.  There  had  been  no  haemoptysis, 
and  the  dyspnoea  had  existed  very  little  more  than  six  months. 
For  more  than  a  year  the  appetite  had  sensibly  diminished,  and 
during  the  last  four  months  had  altogether  ceased  ;  the  thirst 
was  urgent  and  diarrhoea  frequent.  The  patient  did  not  re- 
collect having  had  perspirations  ;  he  had  complained  of  rigors 
the  last  fifteen  days. 

On  the  17th  of  February,  extreme  emaciation  ;  no  head- 
ache, or  pains  in  the  limbs  or  loins  ;  intellectual  faculties, 
clear  ;  speaking  hurried  ;  voice,  without  huskiness  ;  breathing, 
rapid  ;  cough,  rather  frequent,  and  occasionally  in  paroxysms  ; 


Chap.  7.]  tubercles;  cysts.  119 

expectoration,  scanty,  greenish-colored  and  opaque  ;  percus- 
sion, every  where  clear;  resonance  of  voice  and  pectoriloquy 
between  the  scapulœ,  and  under  the  right  axilla.  Skin,  dry  ; 
temperature  increased  towards  the  evening  ;  no  perspiration 
or  rigors  the  preceding  night  ;  pulse,  moderately  frequent. 
Tongue,  clean  and  natural  on  edges  ;  thirst,  urgent  ;  very 
little  appetite  ;  epigastrium,  not  painful  ;  occasional  nausea 
after  cough  ;  four  liquid  stools  ;  colic  pains  with  flatus. 

In  the  succeeding  days,  some  increase  of  the  diarrhoea,  but  no 
sensible  change  in  the  other  symptoms.  There  was  a  slight 
deafness  from  the  12th  to  the  15th  of  May,  when  death  took 
place,  preceded  by  delirium,  the  last  twenty-four  hours. 

Opening  of  the  cor'pse  thirty-six  hours  after  death. 

Exterior.  —  Nothing  worth  noticing.  (The  brain  was 
removed  for  anatomical  purposes). 

Thorax.  —  Adhesions  of  the  upper  and  posterior  parts  of 
both  lungs  to  costal  pleurae.  A  small,  tuberculous  excavation 
existed  in  the  summit  of  the  left  lung,  which  offered  in  the  rest 
of  its  extent,  numerous  grey,  semi-transparent  granulations, 
surrounded  by  healthy  lung.  By  making  a  vertical  section 
from  the  summit  to  the  base,  numerous  rounded  openings 
were  seen,  formed  by  the  more  or  less  thickened  and  uniform- 
ly dilated  bronchia,  their  dilatation  extending  nearly  to  the 
surface  of  the  lung.  The  same  state  of  things  existed  in  the 
right  lung,  where  the  excavation  in  the  summit  was  small,  the 
granulations  in  still  greater  number,  and  the  bronchial  dilata- 
tion more  considerable  than  in  the  left  ;  heart,  of  moderate 
volume. 

Abdomen.  —  Mucous  membrane  of  stomach  red  around  the 
cardiac  orifice  ;  some  ulcerations  in  small  intestine  ;  others  of 
large  dimensions  in  the  cascum.     The  colon  and  other  viscera, 


120    PATHOLOGICAL  ANATOMY.  URINARY  ORGANS  ;    [Part  1, 

with  the  exception  of  the  right  kidney,  were  heahhy.  This 
-kidney  presented  its  natural  volume  and  situation  ;  it  was  of  a 
light  yellow  color,  nodulated  in  its  upper  third,  and  had  noth- 
ing remarkable  below.  The  corresponding  ureter  was  hard 
to  the  touch,  about  four  lines  in  diameter,  diminishing  both  in 
size  and  density  as  it  approached  the  bladder.  The  renal 
parenchyma  was  destroyed  in  the  upper  third,  and  replaced 
by  a  yellowish,  opaque  substance,  in  every  respect  tubercu- 
lous, lying  on  a  false  membrane  of  a  similar  nature.  The  latter 
was  prolonged  inferiorly,  lining  the  pelvis  and  ureter,  to  the 
parietes  of  which  it  was  firmly  adherent.  Consistent  on  its 
adherent,  it  became  gradually  soft  and  friable  towards  its  free 
surface  ;  it  was  from  half  a  line  to  a  line  in  thickness,  and  firmer 
in  the  ureter  than  elsewhere.* 

176.  Most  unaccountably  we  omitted  to  examine  the  blad- 
der ;  we  are,  therefore,  ignorant  whether  this  tuberculous 
membrane  was  prolonged  into  its  cavity.  And  although  this 
does  not  appear  probable,  from  the  fact  that  the  consistence 
and  thickness  of  the  ureter  diminished  on  approaching  the 
bladder,  we  shall  refrain  from  any  conjecture  on  the  subject. 

177.  Of  the  two  other  cases,  one  was  a  young  man,  aged 
18,  of  pretty  strong  constitution,  generally  in  good  health,  not 
liable  to  colds,  and  who  died  of  phthisis  after  an  illness  of  seven 
months.  Among  other  morbid  alterations,  we  observed  nu- 
merous ulcerations  in  both  intestines,  some  tuberculous  granu- 
lations, and  atasnia  in  the  portionof  jejunum  joining  the  ileum  ; 

"  Laennec  mentions  an  instance  where  the  ui'eters  were  "  so  much 
dilated  as  to  receive  the  thumb,  and  their  internal  coat  converted 
into  an  adhesive  layer  of  tuberculous  matter."  These  examples  pre- 
sent an  interesting  variety  in  the  mode  of  tubercular  deposition.  — 
Cowan. 


Chap.  T.]     TUBERCLES  ;  inflammation  ;  cause.  121 

a  great  number  of  tubercles  in  the  mesentery  ;  the  two  kidneys 
redder  than  natural  ;  and  in  the  summit  of  the  right  was  an 
oval  tubercle,  not  encysted,  about  an  inch  in  its  greatest 
diameter,  of  a  lemon  yellow  color  and  of  good  consistence. 

The  other  example  was  also  a  young  man,  of  weak  consti- 
tution, who  died  of  phthisis  five  months  from  its  beginning. 
The  intestinal  mucous  membrane  was  perfectly  healthy  in  con- 
sistence, color  and  thickness.  No  tubercles  in  the  mesentery  ; 
they  were,  however,  numerous  on  each  side  of  the  lumbar 
vertebrae,  around  the  upper  margin  of  the  pelvis  and  in  the 
neck.  One  of  the  cones  in  the  summit  of  the  right  kidney 
was  converted  into  tuberculous  matter,  a  little  softened  at  the 
centre.  The  adjoining  cone  offered  here  and  there  a  small 
quantity  of  the  same  substance.  The  intervening  tissue  was 
healthy. 

178.  In  both  these  last  instances  we  have  carefully  exam- 
ined the  state  of  the  mucous  membrane  of  the  bladder  and 
ureters,  and  have  found  it  free  from  alteration.  We  cannot, 
therefore,  attribute  the  development  of  the  tuberculous  matter 
in  the  kidney  to  inflammation  of  this  membrane.  And,  in  the 
previous  observation,  how  can  we  suppose  the  false  membrane 
lining  the  pelvis  and  ureter,  to  have  been  the  product  of  in- 
flamed lymphatic  vessels,  which  by  many  medical  men  are 
considered  the  source  of  tubercles  ? 

179.  The  bladder,  more  or  less  contracted  or  distended, 
never  presented  any  morbid  alteration.  We  have  even 
scarcely  observed  slight  injection  of  its  mucous  membrane. 

IN    PATIENTS     WHO    DIED    OF     OTHER    DISEASES. 

180.  In  nearly  two  hundred  fatal  cases  of  other  diseases, 
we  have  carefully  inspected  the  kidneys,  without  ever  finding 

p 


122     PATHOLOGICAL  ANATOMY. GENITAL  ORGANS  ;    [Part  I 

the  slightest  trace  of  tuberculous  matter.  The  other  changes 
were  the  same  with  those  occurring  in  phthisis.  With  two 
exceptions  we  have  also  constantly  seen  the  mucous  mem- 
brane of  the  bladder  free  from  all  alterations  in  these  subjects. 


CHAPTER    VIII 


GENITAL  ORGANS. 


A  RT I C  L  E     I . 

MALE  GENITAL  ORGANS. 

181.  In  the  small  number  of  instances  in  which  we  have 
examined  the  penis  of  phthisical  patients,  we  have  observed 
nothing  worth  remarking.  But  out  of  forty  cases  where  the 
prostate,  vesiculae  séminales  and  vasa  deferentia  were  scrupu- 
lously examined,  three  presented  a  greater  or  less  quantity  of 
tuberculous  matter  in  the  prostate  ;  and  in  one  of  these  (the 
subject  of  the  following  observation),  it  occupied  the  prostate, 
vesiculse  séminales  and  vasa  deferentia. 


SIXTH     OBSERVATION. 

A  German  tailor,  aet.  24,  of  rather  weak  constitution,  but 
little  subject  to  illness,  having  a  fair  skin,  light  hair,  regular 
shape  and  spare  habit,  was   admitted  into  the  hospital  of  La 


Chap.    8.]       TUBERCLES    IN    THE    PROSTATE,    &;C.  123 

Charité,  October  27th,  1824.  He  had  been  ill  fifteen  days, 
and  was  attacked  in  the  commencement  of  his  illness,  while  in 
perfect  health,  and  without  any  apparent  cause,  with  a  mod- 
erately copious  haemoptysis,  which,  in  spite  of  being  twice 
bled,  repose  and  abstinence,  has  since  continued.  A  cough 
began  at  the  same  time,  since  which  he  has  experienced  a 
sense  of  heat  and  copious  night  perspirations  ;  the  appetite  had 
diminished,  and  thirst  much  increased.  No  burning  sensation 
or  pain  in  chest. 

28th.  Surface  of  body,  including  lips  and  tongue,  pale  ;  pros- 
tration ;  breathing,  rather  quick  ;  cough,  rather  frequent  ;  a  por- 
tion of  the  spitting  vessel  was  occupied  by  blood,  more  or  less 
frothy,  fluid  and  blackish  ;  percussion  of  chest,  clear  ;  respira- 
tion, distinct,  rather  weaker  under  the  clavicles  than  else- 
where ;  pulse,  weak,  slightly  accelerated,  at  ninety  ;  heat  of 
surface,  natural  ;  thirst,  rather  urgent  ;  appetite,  much  dimin- 
ished ;  abdomen,  not  painful  ;  stools,  rare. 

(Venesection  of  |  viij.  ;  common  emulsion  for  drink  ;  mus- 
tard foot-baths). 

The  haemoptysis  ceased  entirely  on  the  30th,  and  did  not 
again  return. 

During  the  three  following  months,  that  is,  until  the  5th  of 
February,  1825,  the  day  of  his  death,  the  cough  was  usually 
very  violent  during  the  night;  expectoration,  copious,  consisting 
at  first  of  a  clear  fluid,  but  at  the  end  of  November,  and  during 
the  following  month,  this  was  associated  with  sputa  of  an  opaque 
and  at  times  nummulated  appearance.  These  were  of  greyish 
color,  semi-vitrified,  as  it  were,  and  scanty  during  the  whole 
of  January.  On  the  2d  of  December,  respiration  under  the 
clavicles  was  coarse,  but  without  any  râle.  This  character 
was  still  more  evident  on  the  9th  of  January,  and  in  the  an- 
terior and  inferior  half  of  the  left  side,  and  every  where  pos- 


124  PATHOLOGICAL  ANATOMY.  GENITAL  ORGANS  ;  [Part  I, 

teriorly,  the  respiratory  murmur  was  mingled  with  a  quite  fine 
crepitation  ;  the  percussion  there  remained  constantly  clear. 
On  the  25th,  there  was  very  great  dulness  of  sound  about 
three  inches  under  the  left  clavicle,  and  in  the  same  region 
well  marked  pectoriloquy.  From  the  middle  of  January  the 
dyspnœa  was  considerable.  No  pains  were  complained  of  in 
the  larynx  or  in  the  region  of  the  trachea  ;  the  voice  became 
changed  only  eight  days  before  death. 

Slight  acceleration  of  the  pulse  during  the  months  of  No- 
vember and  December,  which  afterwards  increased,  and  from 
the  15th  to  the  20th  of  January  it  varied  from  ninety-five  to 
one  hundred  and  ten.  The  heat  increased  proportionably  ; 
constant  night  sweats,  which  were  in  general  limited  to  the 
upper  part  of  the  body  ;  there  were  also  some  irregular  rigors 
during  the  last  month. 

Very  shortly  after  the  entrance  of  the  patient  into  the  hospital 
his  appetite  increased,  and  he  took  more  food,  so  that  by  the 
end  of  November  and  the  following  month,  he  ate  a  fourth  or 
half  of  the  usual  house  allowance.  Stools  rare,  bowels  open- 
ed by  eneraata  of  flaxseed  tea,  during  the  first  two  months  ; 
the  evacuations  then  became  frequent  and  fluid.  No  colic, 
nausea  or  vomiting  ;  thirst  always  urgent. 

After  the  diarrhoea  commenced  the  debility  rapidly  increas- 
ed ;  and  during  the  last  twenty  days  the  patient  was  confined 
to  his  bed.  There  was  slight  delirium  a  few  hours  before 
death,  coming  on  at  four,  p.  m. 

A  blister  was  applied  to  the  left  arm  from  the  beginning  of 
December,  and  from  the  same  time  frictions  of  the  bydrio- 
date  of  potash  every  morning  in  each  axilla  were  employed  to 
within  a  few  days  of  death. 


Chap.  8.]    TUBERCLES  IN  THE  PROSTATE,  StC.       125 

Opening  of  the  corpse  forty  Jiours  after  death. 

Exterior.  —  Almost  extreme  emaciation  without  œdema. 

Head.  —  Very  trifling  infiltration  beneath  the  arachnoid  ; 
some  white,  opaque,  miliary  granulations  attached  to  this 
membrane  along  the  longitudinal  fissure  ;  a  spoonful  of  limpid 
fluid  in  the  left  lateral  ventricle  ;  rather  less  in  the  right  ;  two 
more  in  the  lower  occipital  fossae.  Immediately  below  the  pons 
varolii  and  in  the  substance  of  the  medulla  oblongata,  there 
was  a  tubercle,  about  the  dimensions  of  a  middle-sized  pea, 
neither  encysted  nor  softened,  and  round  which  the  medullary 
substance  was  healthy.  The  remainder  of  the  cerebral  mass 
was  sound. 

Neck. —The  epiglottis  had  nothing  unnatural  about  it. 
There  was  a  deep,  round  ulceration,  one  line  and  a  half  in  di- 
ameter, at  the  junction  of  the  vocal  cords.  Lower  portion  of 
tracheal  mucous  membrane  slightly  reddened,  but  of  natural 
thickness  and  consistence. 

Thorax.  —  From  four  to  five  ounces  of  clear  fluid  in  each 
of  the  pleurée.  A  white,  narrow  band  extended  from  the  costal 
pleura  to  the  summit  of  the  left  lung,  where  it  terminated  in  a 
point  corresponding  to  a  tuberculous  excavation.  The  whole 
of  the  upper  lobe  was  indurated,  and  offered  numerous  yellow 
spots  at  its  surface,  and  two  small  cavities  in  its  summit  ; 
every  where  else  there  was  an  almost  infinite  number  of  irreg- 
ularly shaped  tubercles,  varying  in  size  from  that  of  a  pea  to 
a  hazel-nut,  frequently  confluent,  and  occasionally  softened 
or  incompletely  excavated.  They  were  less  numerous  in 
the  lower  lobe,  where  none  of  them  were  softened.  Nearly 
all  were  surrounded  with  hepatized  pulmonary  tissue.  The 
inferior  lobe  of  the  right  lung  was  slightly  engorged,  but 
presented  no  tubercles.     The  latter  were  also  less  numerous 


126    PATHOLOGICAL  ANATOMY. GENITAL  ORGANS  ;    [Pai't  I, 

in  the  upper  lobe  of  this  lung  than  in  that  of  the  left  ;  none 
-of  them  were  softened.  In  neither  lung  could  we  detect  the 
grey,' serai-transparent  matter.  The  broncliia  were  of  a  uni- 
form pink  tint.     Heart,  small  and  healthy  ;  aorta,  natural. 

Abdomen.  —  The  stomach  contained  a  large  quantity  of 
green  bile  and  a  little  thick  tenacious  mucus.  Its  lining  mem- 
brane was  of  a  yellow  color,  and  much  softened  in  a  small 
portion  of  the  great  cul-de-sac.  In  an  elongated  surface  of 
from  five  to  six  square  inches  along  the  great  curvature,  it 
was  mamillated,  of  a  greyish  red,  more  than  half  a  line  thick, 
and  evidently  raised  above  the  surrounding  parts.  Elsewhere 
it  was  sound.  The  condition  of  the  raucous  membrane  of  the 
small  intestine,  in  its  upper  third,  was  healthy  ;  it  presented 
some  transverse  ulcerations  in  the  middle  third,  and  in  the 
lower  portion,  some  longitudinal  and  elliptical  ulcerations, 
similar  in  shape  to  the  patches  in  which  they  were  situated. 
The  transverse  ulcerations  did  not  encircle  the  intestine  ;  they 
were  from  an  inch  to  an  inch  and  a  half  wide  in  their  centre, 
gradually  narrowing  at  either  extremity.  The  corresponding 
mucous  membrane  was  completely  removed,  and  the  ulcerated 
surface  very  uneven,  owing  to  the  thickened  and  partially 
destroyed  submucous  layer.  Their  edges  were  prominent,  of 
a  reddish  and  yellowish  tint,  in  consequence  of  the  presence  of 
numerous  softened  tubercles  in  the  substance  of  the  submucous 
tissue.  Externally  the  portion  of  intestine  corresponding  to 
the  ulcerations,  was  more  or  less  greyish  or  violet-colored,  pre- 
senting inequalities  caused  by  tuberculous  granulations  situated 
between  the  peritoneal  and  muscular  tissues.  The  longitudi- 
nal ulcerations  were  not  complete  ;  that  is,  the  mucous  mem- 
brane was  only  partially  destroyed.  Their  surfaces  were 
uneven,  like  those  of  the  previous  patches,  both  from  this 
cause  and  in  consequence  of  a  number  of  strips  formed  by 


Chap.  8.]         TUBERCLES    IN    THE    PROSTATE,    &;C.  127 

the  mucous  membrane.  The  intervening  mucous  mem- 
brane was  healthy.  It  was  pale,  thickened,  and  of  the  con- 
sistence of  mucus,  throughout  the  whole  of  large  intestine. 
The  caecum  and  right  lumbar  colon  offered  five  small,  ir- 
regular, tuberculated  ulcerations,  leaving  the  muscular  coat 
exposed.  The  mesenteric  glands  were  increased  in  vol- 
ume, and  almost  wholly  tuberculous;  this  was  also  the  case 
with  many  of  the  mesocaecal  and  also  of  the  right  mesocolic 
glands.  Liver,  pale  and  slightly  adipous  ;  the  bile  of  the 
gall-bladder  very  thick  and  very  dark-colored.  The  spleen 
contained  ten  or  twelve  tuberculous  granulations  of  the  size  of 
a  green  pea,  and  its  tissue  was  redder  than  natural.  Kidneys 
and  bladder,  healthy. 

The  prostate  presented  its  usual  volume,  and  was  almost 
entirely  converted  into  tuberculous  matter,  which  was  not 
softened.  The  vesiculas  séminales  were  rather  voluminous^ 
indurated,  and  filled  with  very  firm,  tuberculous  substance, 
divided  into  masses  by  the  natural  cellular  intersections  of  the 
part.  These  intersections  were  indurated,  greyish-colored, 
more  than  half  a  line  thick,  and  resembling  the  external  cov- 
ering of  the  vesiculae.  From  their  junction,  and  for  about 
three  inches  farther,  the  vasa  deferentia  were  about  two  lines 
in  diameter,  and  offered  the  resistance  of  a  tense  cord.  At 
the  end  of  this  distance  they  decreased  ;  their  parietes  were 
twice  their  usual  thickness,  opaque,  like  those  of  the  vesiculœ 
and  their  cavity,  filled,  in  the  space  indicated  with  firm,  un- 
softened,  tuberculous  matter.     Beyond  this  all  was  natural.* 

*  These  rare  examples  of  tuberculous  deposition  on  mucous  mem- 
branes are^remarkable,  we  think,  from  the  surface  on  which  it  took  place, 
and  not  from  any  peculiarity  in  the  mode  of  its  formation.  The  structure  of 
the  parts  enabled  us  here  to  see  the  mechanism,  as  it  were,  of  morbid  pro- 
ducts, which  we  are  inclined  to  believe  is  similar  to  what  takes  place  in  all 


128     PATHOLOGICAL  ANATOMY. GENITAL  ORGANS  ;  [Part  I, 

128.  Without  fixing  our  attention  upon  every  point  of  this 
observation  worthy  of  interest,  we  will  observe  that  the  form 
and  internal  anatomical  arrangement  of  the  vesiculce  séminales 
were  not  destroyed  ;  that  there  was  no  transformation  of 
tissue,  but  a  simple  development  of  tuberculous  matter  ;  that 
this  development  was  the  product  of  a  morbid  secretion  in  the 
vesiculae  and  vasa  deferentia,  such  as  took  place  in  the 
ureter,  which  we  have  described  in  the  preceding  chapter. 
We  would  remark,  likewise,  that  these  facts  are  very  analo- 
gous to  the  cases  of  tuberculous  peritonitis  we  shall  shortly 
describe,  and  that  they  are  contrary  to  the  opinion  of  those 
who  consider  tubercles  as  the  products  of  the  inflammation  of 
the  lymphatic  vessels  (178). 

183.  Another  circumstance  merits  to  be  remarked  ;  viz. 
that  the  tuberculous  matter,  elsewhere  deposited  than  in  the 
lungs,  as  in  the  spinal  marrow,  layers  of  the  mesentery,  spleen, 
prostate,  &;c.,  was  every  where  at  the  same  stage  of  develop- 
ment, not  yet  softened  ;  which  seems  to  indicate  the  existence 
of  a  common  cause  acting  at  once  on  all  these  points. 

IN  PATIENTS   WHO   DIED   OF   OTHER  ACUTE  AND   CHRONIC   DISEASES. 

After  other  acute  and  chronic  diseases,  we  have  never  ob- 
served tubercles  in  the  prostate,  vesiculae,  séminales,  or  vasa 
deferentia. 

our  tissues  ;  viz.  production  of  something  not  previously  existing,  gradually 
destroying  the  natural  structure,  but  not  resulting  from  its  transformation.  — 
CowAW.  —  See  Carswell  on  Tubercle.  Illustrations  of  Pathological  Anat- 
omy.   London.  —  H.  I.  B. 


Cîiap.   9.]  VAGINA,    UTERUS,    OVARIES/  129 


ARTICLE    II. 


FEMALE  GENITAL  ORGANS. 


184.  With  the  exception  of  their  size,  they  were  almost 
always  natural.  The  color  of  the  vagina  was  either  white, 
pink,  or  livid,  and  this  nearly  in  the  same  proportion  as  in 
cases  fatal  from  various  other  diseases  ;  it  did  not  seem  to 
depend  upon  the  more  or  less  embarrassed  state  of  the  circu- 
lation. In  no  instance  have  the  parietes  of  the  vagina  pre- 
sented any  organic  lesion. 

185.  The  uterus  was  generally  diminished  in  volume.  As 
in  other  diseases,  we  have  often  observed  some  soft,  small, 
pale-colored  polypi  in  the  cavity  of  the  body  or  neck.  Occa- 
sionally fibrous  bodies  of  inconsiderable  volume  were  devel- 
oped in  the  wall  of  the  uterus,  at  a  variable  distance  from  its 
peritoneal  covering.  In  one  case,  we  found  the  most  super- 
ficial layers  of  the  internal  surface  of  the  fundus  and  neck,  for 
about  a  line  in  depth,  transformed  into  tuberculous  matter 
(Obs.  32),  and  immediately  beneath  this,  surrounded  by 
healthy,  structure,  some  yellowish  miliary  granulations  of  the 
same  nature.  In  this  patient  the  menstruation  had  continued 
regular  to  within  three  months  of  her  death  ;  we  may,  there- 
fore, presume  that  the  development  of  the  tuberculous  matter 
took  place  subsequently  to  that  period. 

We  have  twice  observed  a  small  quantity  of  the  same  sub- 
stance in  the  ovaries.  These  frequently  presented  serous 
cysts  usually  of  small  volume,  and  in  nearly  the  same  propor- 
tion as  after  other  chronic  diseases. 


130  PATHOLOGICAL    ANATOMY.  PERITONEUM  ;    [Part  I, 

IN    PATIENTS     WHO    DIED     OF     OTHER    CHRONIC    DISEASES. 

1S6.  We  have  found  tuberculous  matter  in  the  uterine 
parietes  only  in  cases  of  phthisis  ;  while  the  other  alterations 
were  nearly  equally  frequent  in  this  and  in  other  chronic 
affections. 


CHAPTER    IX 


PERITONEUM. 


187.  There  were  many  examples  of  serous  effusion  into 
the  peritoneum.  We  have  observed  it  (varying  from  one  to 
eight  quarts)  twenty-two  times,  that  is,  in  one  fifth  of  the 
cases.  The  men  were  equally  affected  as  the  women  ;  and 
it  v/as  not  more  frequent  where  the  liver  was  adipous  and  the 
mesentery  tuberculous  than  when  these  alterations  were  not 
present. 

188.  Besides  the  effusion,  we  found  occasionally  a  yellow- 
ish, soft,  false  membrane,  and  a  certain  quantity  of  thick  pus, 
inodorous,  such  as  exists  in  acute  abscesses  (Obs.  4,  16,  31). 
This  double  alteration  was  present  in  four  cases,  and  could 
only  be  the  result  of  an  acute  peritonitis  ;  and  the  symptoms 
observed  during  life  proved  that  the  inflammation  was  devel- 
oped a  few  days,  or  more  frequently  only  twenty-four  hours 
before  death. 

The  fourth  and  sixteenth  observations  confirm  the  truth  of 
this  assertion.  In  another  instance  (Obs.  31),  peritonitis  ap- 
peared to  have  come  on  likewise  during   the  last  twenty-four 


Chap.  9.]  MEMBRANES    AND    ADHESIONS.  131 

hours.  We  did  not  observe  the  symptoms,  but  feel  entitled 
to  attribute  to  it  the  extreme  restlessness  experienced  by  the 
patient  the  evening  preceding  death,  and  which  was  remarked 
by  the  attendants  in  the  ward. 

These  few  facts  show  that  the  peritoneum,  like  the  other 
organs,  is  susceptible  of  acute  inflammation  in  the  last  periods 
of  phthisis,  and  that  the  symptoms  of  it  are  very  often  similar 
to  those  which  it  excites  under  very  different  circumstances. 

189.  Old  cellular  and  partial  adhesions  were  present  in 
three  cases;  in  a  fourth  they  were  universal  (Obs.  14),  result- 
ing from  a  chronic  peritonitis  experienced  by  the  patient  two 
years  and  a  half  before  death. 

190.  In  another  instance  (Obs.  48),  we  have  seen  on  the 
surface  of  the  peritoneum,  covering  the  great  omentum,  nume- 
rous semi-transparent,  miliary  granulations,  as  if  lying  embed- 
ded in  an  incompletely  opaque  false  membrane,  and  they 
were  raised  with  it.  We  have  also  found  between  the  layers 
of  false  membrane,  covering  the  intestines  and  the  anterior  pa- 
rietesofthe  abdomen,  patches  of  tuberculous  matter  of  various 
dimensions  (Obs.  32).  Lastly,  in  a  very  remarkable  instance 
which  we  shall  now  relate,  we  have  seen  the  same  matter  de- 
veloped in  the  omentum  and  mesocolon. 


SEVENTH     OBSERVATION. 

A  BONNET  maker,  aet.  27,  of  a  weak  constitution,  a  month 
in  Paris,  was  admitted  into  the  hospital  of  La  Charité,  April 
7th,  1824,  and  stated  that  he  had  been  ill  five  weeks.  His 
illness  commenced  after  a  severe  wetting,  while  upon  his 
journey,  and  was  marked  by  cough,  expectoration,  rigors,  and 


132  PATHOLOGICAL  ANATOMY. PERITONEUM  ;      [Part  I, 

partial  diminution  of  appetite.  These  symptoms  persisted  ; 
the  thirst  became  considerable  and  anorexia  complete.  The 
shiverings  returned  from  the  slightest  cause  ;  the  cough  had 
much  increased  the  last  eight  days,  and  he  had  since  been 
sensible  of  dyspnœa.  Weakness  was  present  from  the  com- 
mencement, and  soon  accompanied  with  swelling  of  the  legs. 
The  patient  had  not,  however,  kept  his  bed  ;  he  took  a  little 
exercise  everyday,  and  had  not  felt  any  pain  in  the  abdomen. 

On  the  8th  of  April,  face,  pale  ;  slight  oedema  round  the 
ankles  ;  considerable  loss  of  strength  ;  the  sputa  were  greenish 
or  yellowish,  partially  opaque,  mingled  with  others  of  a  greyish 
color,  semi-transparent,  and  as  if  vitrified  ;  cough,  rare  ;  con- 
siderable oppression  ;  speaks  hurriedly  ;  a  mucous  râle  pos- 
teriorly and  principally  in  the  left  side,  from  the  summit  to 
the  base  of  the  lung  ;  percussion,  clear  ;  pulse,  somewhat  ac- 
celerated ;  heat,  moderate  ;  tongue,  dry,  rather  red  :  mouth, 
clammy  ;  thirst,  urgent  ;  anorexia  ;  abdomen,  tense,  elevated, 
every  where  rather  clear  on  percussion  and  not  painful  ;  how- 
ever, at  moments  the  patient  complained  of  slight  uneasiness. 
Bowels  costive. 

(Decoction  of  the  triticum  repens  with  oxymel  and  nitre  ; 
two  enemas  of  parietaria  ;  gum  potion  ;  two  rice  creams  ; 
broth  three  tim.es  daily.) 

The  same  symptoms  continued  with  variable  intensity  until 
death,  which  took  place  on  the  29th  of  August.  Their  in- 
crease was  gradual,  almost  unperceived  ;  the  cough,  generally 
very  feeble  ;  expectoration,  never  abundant,  and  not  varying 
in  its  characters  from  what  we  have  already  described.  On 
some  days  the  patient  neither  coughed  nor  expectorated. 
During  the  last  three  months  the  lower  two  thirds  of  the  right 
side  of  chest  were  completely  dull  ;  the  respiratory  murmur, 
very  distant  and  obscure  in  the  same  part  ;  there  was  an  oc- 


Chap.  9.]    TUBERCULOUS    MEMBRANES  ;    ADHESIONS.  133 

casional  crackling  sound  under  the  corresponding  clavicle.  To 
the  left  the  respiration  was  a  little  weaker  in  the  latter  region 
than  in  the  lower  portion  of  the  same  side,  occasionally  min- 
gled with  a  mucous  râle,  and  now  and  then  with  a  slight 
indistinct  crepitation. 

For  the  first  fifteen  days  the  pulse  was  rather  accelerated  ; 
it  afterwards  became  calm,  and  again  more  frequent  towards 
the  fatal  termination  ;  it  was  always  weak  and  regular.  The 
increased  temperature  varied  with  the  state  of  the  circulation, 
and  ceased  when  the  pulse  became  natural  in  frequency.  It 
was  seldom  observed  at  night,  and  perspirations  were  still 
more  rare. 

The  tongue  was  almost  constantly  red  and  dry  during  the 
whole  of  these  four  months  ;  a  small  ulceration  near  its  point 
and  on  the  right  side  was  observed  during  the  last  few  days. 
The  thirst  diminished  with  the  decrease  of  febrile  movement, 
and  re-appeared,  though  slightly,  with  its  augmentation. 
After  some  days  of  abstinence  the  appetite  returned,  and  the 
desire  for  food  afterwards  was  urgent,  but  some  rice  creams 
(crèmes  de  riz)  and  a  little  milk  were  alone  permitted.  Nau- 
sea, rare  ;  no  vomitings.  Abdomen,  rnore  or  less  voluminous, 
with  occasional  uneasiness.  No  colic  pains  at  any  time. 
Diarrhœa  came  on  at  the  end  of  May,  persisted  in  the  begin- 
ning of  June,  then  ceased,  returned  at  different  intervals,  and 
was  very  copious  during  the  last  twenty  days. 

The  countenance  lost  speedily  the  slight  color  which  it  had 
and  became  pale  and  slightly  yellow.  The  patient  felt 
wearied  by  the  duration  of  his  illness,  without,  however,  suf- 
fering much  disquietude  ;  he  spoke  only  of  the  increased  size 
of  the  abdomen,  which  incommoded  him,  and  which  he 
ascribed  to  flatulence.  Rapid  emaciation,  very  gradual  de- 
crease of  strength,  so  that  to  the  last  day  he  perambulated  the 


134  PATHOLOGICAL    ANATOMY.  PERITONEUM  ;    [Part  I, 

wards  of  the  hospital.  The  tendency  to  sleep  increased  with 
the  weakness.  On  the  29th  of  August,  at  nine,  p.  m.,  he  rose 
for  the  purpose  of  placing  himself  on  a  night-stool,  and  had 
scarcely  done  so,  when  he  fell  back  against  the  wall.  He  was 
lifted  into  bed,  and  in  a  quarter  of  an  hour  afterwards  again 
rose,  was  assisted  in  lying  down  by  the  nurse,  and  at  half  past 
nine  expired  without  a  struggle. 

The  treatment  consisted  in  the  use  of  demulcents,  slight 
diuretics,  and  weak  astringents. 

Opening  of  the  corpse  thirty-four  hours  after  death. 

Exterior.  —  Universal  emphysema,  especially  of  the  neck 
and  lateral  parts  of  trunk,  accompanied  with  bullae,  contain- 
ing a  violet-colored  fluid.  The  arms,  though  crepitating 
on  pressure,  were  very  small,  so  extreme  was  the  ema- 
ciation. 

Head.  —  Two  small  spoonsful  of  clear  fluid  on  the  upper 
portion  of  the  arachnoid  ;  a  larger  quantity  in  the  occipital 
fossas.  Very  slight  sub-arachnoidean  infiltration.  Brain,  rather 
soft  ;  consistence  of  septum  lucidum  and  inferior  surface  of 
fornix  almost  pulpy.  About  a  spoonful  of  serum  in  each 
lateral  ventricle. 

Neck.  —  Epiglottis  and  larynx,  healthy.  Mucous  mem- 
brane of  the  trachea,  of  a  livid  pink  color,  of  natural  thickness 
and  consistence. 

Chest.  —  Left  lung,  without  any  adhesions,  of  a  dirty  grey 
color,  interrupted  by  whitish  spots,  corresponding  to  masses  of 
grey  and  tuberculous  matter,  which  were  larger  and  more  nu- 
merous in  the  upper  than  in  the  lower  lobe.  There  was  no  ex- 
cavation, and  the  surrounding  parenchyma  was  healthy.  The 
right  lung  presented  the  same  lesion,  and  its  two  lower  thirds 
were  covered  by  a  false  membrane,  united  to  one  lining  the 


Chap.  9.]        TUBERCULOUS  OMENTUM.  1.35 

costal  pleura,  by  means  of  filaments,  enclosing  in  their  inter- 
stices about  ten  ounces  of  clear  serous  fluid.  The  bronchia 
were  thin  and  of  a  yellowish  red  tint.  The  heart  was  of  usual 
dimensions,  containing  a  small  quantity  of  pale,  frothy  blood. 
Its  parietes  were  flaccid  ;  both  ventricles  thinner  than  natu- 
ral ;  the  left  was  only  three  lines  thick.  They  were  so  supple 
that  at  first  sight  the  muscular  fibres  seemed  separated  one 
from  another  by  a  certain  quantity  of  air,  but  this  was  not 
really  the  fact. 

Abdomen.  —  Its  anterior  parietes  adhered  to  the  subjacent 
viscera,  by  means  of  cellular  filaments  of  various  lengths. 
The  omentum  covered  the  greater  part  of  the  small  intestine, 
forming  a  mass  from  twelve  to  fifteen  lines  thick,  uneven, 
alternately  yellow  and  blueish  in  color,  composed  of  the  tuber- 
culous and  purplish-grey,  semi-transparent  matter.  The 
former  occupied  four  fifths  of  the  mass,  and  was  no  where 
softened.  The  mesocolon  and  mesorectum  presented  the 
same  alteration,  but  were  only  half  as  thick  as  the  omentum. 
The  greater  number  of  the  mesenteric  glands  were  tuber- 
culous. The  liver  adhered  to  the  diaphragm  by  means  of  a 
false  membrane  easily  separated.  It  was  of  a  deep  yellowish- 
brown  color,  of  very  moderate  volume,  exceedingly  soft,  and 
its  specific  gravity  so  inconsiderable,  that  it  floated  in  water 
like  a  healthy  lung.  Internally,  there  was  an  infinite  num- 
ber of  cavities,  varying  in  size,  from  a  hemp-seed  to  that  of  a 
pea,  and  rather  empty  than  full.  The  bile  in  the  gall-bladder, 
clear  and  scanty.  The  spleen,  rather  larger  than  usual.  Its 
peritoneal  covering  detached  in  its  inferior  half,  formed  a  sack 
containing  at  least  two  ounces  of  a  blackish  fluid.  Its  tissue 
was  quite  soft  and  similar  in  color  to  the  fiuid  just  mention- 
ed. Kidneys,  natural.  Stomach,  partially  covered  by  a  false 
membrane.     Although  the  organ  was  remoyed  with  the  great- 


136  PATHOLOGICAL    ANATOMY. PERITONEUM,      [Part  I, 

est  possible  care,  it  offered,  to  the  left  of  the  cardiac  orifice, 
a  circular  perforation  with  pale  and  thin  edges.  But  from  the 
absence  of  effusion,  we  ought  to  conclude  that  the  perforation 
was  the  result  of  slight  mechanical  force,  and  did  not  exist 
during  life.  Internally  two  very  different  appearances  were 
present.  Near  the  pylorus,  and  extending  to  some  distance, 
the  mucous  membrane  was  greyish,  mamillated,  of  good  con- 
sistence, and  in  twenty  points  more  or  less  near,  incompletely 
destroyed  over  a  surface  of  two  lines  ;  elsewhere  it  was  of  a 
nearly  white  or  light  brown  color,  and  extremely  soft  and 
thin  ;  the  corresponding  layers  were  easily  torn.  The  mu- 
cous membrane  of  the  small  intestine  every  where  pale  and 
soft  like  mucus  ;  that  of  the  colon  rather  less  so.  No  ulcer- 
ations in  either  intestine. 

191.  This  observation  is  interesting  on  several  accounts. 
With  regard  to  the  tuberculous  matter,  it  presents  a  solitary 
example,  in  our  own  experience,  of  its  equal  development  in 
parts  which  were  examined  in  the  lungs,  mesentery^  omen- 
tum, &;c.  Sic,  while  in  all  our  other  observations,  it  was 
always  further  advanced  in  the  lungs  than  any  where  else. 
The  thoracic  and  abdominal  symptoms  were  in  harmony  with 
the  morbid  condition  of  the  organs. 

The  union  of  a  certain  quantity  of  the  bluish-grey  and  semi- 
transparent  matter  with  the  tubercular  in  the  omentum,  is  an 
additional  argument  in  favor  of  their  mutual  connexion. 

192.  In  many  cases  of  sudden  death,  after  acute  diseases, 
(n)ore  especially  the  eruptive),  we  have  seen  subcutaneous 
emphysema  universal,  but  rarely  so  considerable  as  in  the 
present  instance.  It  is  the  only  example  we  have  met  among 
chronic  affections  ;  and  we  have  never  before  observed  it  in 
the  hepatic  parenchyma.     The  volume  of  the  liver  rather  less 


Chap.  9.]        TUBERCULOUS  OMENTUM.  137 

than  natural,  appears  much  more  remarkable  than  the  emphy- 
sema. For,  supposing  the  latter  to  have  taken  place  either  a 
short  time  after  or  before  death,  the  liver  must  have  previous- 
ly been  extremely  small  ;  and,  as  we  possess  no  example  of 
a  liver  so  diminutive  as  this  supposition  would  infer,  we  are 
almost  forced  to  conclude  that  the  emphysema  was  gradually 
developed  long  before  death,  in  consequence  of  some  peculiar 
but  unknown  alteration  of  the  parenchyma. 

193.  The  flaccidity,  the  elasticity,  the  inconsiderable  thick- 
ness of  the  left  ventricle  of  the  heart,  form  also  a  singular 
combination  of  circumstances,  and  to  a  certain  point  assimilate 
the  state  of  this  organ  with  that  of  the  liver.  We  have  never 
found  the  substance  of  the  spleen  more  completely  softened, 
and  it  is  the  first  time  we  have  observed  its  peritoneal  cover- 
ing partially  detached.  The  morbid  alteration  of  the  mucous 
membrane  of  the  stomach,  small  intestine  and  colon  could 
scarcely  be  more  considerable;  yet  notwithstanding  such 
universal  and  severe  disease,  the  patient  complained  of  no 
pain,  was  almost  without  fever,  and  death  was  still  unex- 
pected. 

194.  In  the  two  preceding  chapters  we  have  seen  the 
tuberculous  matter  deposited  on  the  surface  of  mucous  mem- 
branes, in  the  ureters,  vesiculse  séminales,  and  vasa  deferentiaj 
that  is,  developed  by  means  of  secretion  or  exhalation.  A 
similar  process  no  doubt  took  place  in  the  present  case  in  the 
great  omentum,  and  also  where  masses  of  tuberculous  matter 
were  found  between  the  layers  of  false  membrane  which  lined 
the  cavity  of  the  abdomen.  It  is  even  probable  that  these 
are  not  rare  examples,  and  that  exhalation  is  one  of  the  most 
frequent  means  employed  by  nature  for  the  production  of 
tuberculous  matter.     We   are   the  more  inclined   to  believe 

s 


138  PATHOLOGICAL    ANATOMY. PERITONEUM.    [Part  1, 

this,  since  exhalation  is  also  a  source  of  other  morbid  pro- 
ductions equally  fatal,  as,  for  instance,  that  of  cancer  de- 
veloped on  the  free  surface  of  the  peritoneum. 

IN   PATIENTS    WHO    DIED    OP    OTHER    CHRONIC    DISEASES. 

195.  After  various  other  chronic  diseases,  we  have  seen 
several  cases  of  serous  effusion  into  the  peritoneal  cavity. 
Excluding  diseases  of  the  heart,  in  which  this  is  so  frequent, 
we  have  found  it  sixteen  times  out  of  seventy-seven  cases  ; 
nearly  therefore  in  the  same  proportion  as  in  phthisis.  Acute 
peritonitis,  coming  on  shortly  before  death  was  present  in  four 
cases,  three  of  them  cancerous  affections  of  the  uterus,  one  a 
case  of  dysentery. 

But  in  no  one  of  these  seventy-seven  cases*  have  we  met 
either  tuberculous  peritonitis,  or  grey,  semi-transparent  granu- 
lations on  the  peritoneum,  or  in  layers  of  false  membrane  on 
its  surface.  These  results  concur  with  the  preceding  facts  in 
pointing  out  the  analogy  between  the  tuberculous  and  the 
grey,  semi-transparent  matter,  both  of  which  appear  confined 
to  phthisis. 

*  Up  to  the  present  moment  M.  Louis  has  not  found  a  single  exception  to 
this  law.    Vide  Examen,  de  l'Examen,  page  24.  —  Cowan. 


Chap.   10.]  BRAIN    AND    ITS    MEMBRANES.  139 


CHAPTER    X. 

BRAIN  AND  ITS  MEMBRANES. 

196.  Though  in  phthisis,  the  cerebral  functions  are  undis- 
turbed, and  in  general  continue  so  to  the  last  moment  of  exist- 
ence, we  have,  however,  in  the  majority  of  cases,  found  some 
alteration  in  the  brain,  or  in  the  parts  connected  with  it.  We 
shall  successively  describe  them. 

197.  In  patients  advanced  in  age,  the  dura  mater  was 
more  or  less  adherent  to  the  saggittal  suture  and  its  vicinity  ; 
it  frequently  presented  near  the  longitudinal  sinus,  or  at  a  con- 
siderable distance  from  the  same  part,  lacerations  from  two  to 
four  lines  in  length.  These  gave  passage  to  some  round, 
white,  opaque,  or  semi-transparent  bodies,  of  uniform  struc- 
ture, about  a  line  more  or  less  in  diameter,  and  two,  three,  four, 
or  sometimes  more  in  number  ;  at  the  edge  of  the  lacerations, 
the  dura  mater  was  divided  into  two  laminae  for  a  small  space. 
Occasionally  the  internal  layer  of  the  skull  was  thinned  or  de- 
stroyed in  the  corresponding  point  to  the  extent  of  one  or  two 
lines.  These  bodies  were  more  or  less  adherent  to  the  aper- 
tures in  the  dura  mater,  and  less  frequently  present  in  young 
subjects  than  in  patients  more  advanced  in  age. 

198.  They  were  attached  to  the  upper  surface  of  the  arach- 
noid covering  the  brain,  and  seldom  to  the  layer  lining  the 
dura  mater  ;  they  were  almost  always  present,  whether  the 
latter  membrane  was  or  was  not  perforated.  They  were 
never  farther  than  two  inches  from  the  median  line,  and  in- 
creased in  number  as  they  approached  it.    Their  volume  varied 


140  PATHOLOGICAL    ANATOMY.  BRAIN;  [Part  I, 

from  that  of  a  millet-seed  to  a  green  pea.  They  were  either 
in  groups,  forming  more  or  less  rounded  or  irregular  looking 
patches,  or  disseminated,  closely  attached  to  the  arachnoid, 
which  was  always  thickened  and  opaque  in  the  corresponding 
points.  This  fact  and  the  occasional  absence  of  the  pretended 
glands  of  Pacchioni,  induce  us  to  consider  them  as  morbid 
productions.  We  shall  hereafter  mention  them  under  the 
name  of  "  arachnoidean  granulations." 

199.  In  some  other  instances  the  arachnoid  was  thick, 
opaque,  and  free  from  granulations.  In  two  cases  this  double 
lesion  occupied  the  whole  of  its  upper  surface.  In  two  others 
we  found  fragments  of  a  yellowish  and  extremely  soft  false  mem- 
brane. This  was  evidently  very  recent,  and  proves  that  the 
arachnoid,  like  other  serous  membranes,  is  liable  to  acute  in- 
flammation during  the  last  days  of  life,  when  emaciation  and 
weakness  are  extreme. 

200.  Five  times  out  of  ninety-nine  cases,  there  was  in  the 
upper  part  of  the  arachnoid  a  little  limpid  or  reddish  serosity, 
from  three  to  five  small  sponsful  (Obs.  7,  12,  16,  22,  28). 
Much  more  frequently,  and  in  about  one  half  of  the  examples, 
we  found  in  the  inferior  occipital  fossae  one  or  two  spoonsful 
of  the  same  fluid  ;  and  whenever  we  have  opened  the  spinal 
canal  there  was  a  still  larger  quantity. 

201.  In  three  fourths  of  the  cases,  beneath  the  upper  por- 
tion of  the  arachnoid,  there  was  a  more  or  less  considerable 
serous  infiltration,  which  we  shall  call  subarachnoid  infiltration. 
When  very  partial,  it  generally  occupied  the  posterior  half  of 
the  region  we  have  mentioned.  If  more  abundant,  it  existed 
every  where,  both  in  the  interstices,  and  on  the  surface  of  the 
cerebral  convolutions,  and  when  very  considerable,  it  tvas 
three  quarters  of  a  line  thick  over  the  latter.     The  thicker  it 


Chap.   10.]  EFFUSION    INTO    VENTRICLES.  141 

was  the   more  easily  the  arachnoid  and  pia   mater  could  be 
detached. 

202.  In  twelve  cases,  or  about  one  eighth,  we  found  the 
pia  mater  more  or  less  red,  thick  and  injected.  In  six  of 
these  the  injection  extended  to  the  medullary  substance  of  the 
brain. 

203.  Serous  effusion  into  the  lateral  ventricles  was  equally 
frequent  with  the  arachnoidean  infiltration  (204),  and  in  gen- 
eral proportionate  to  it.  The  quantity  varied  from  one  to  five 
spoonsful  in  each  ventricle.  The  serous  fluid  was  generally 
limpid,  and  we  have  never  found  it  turbid  except  in  three 
subjects,  and  in  no  one  did  we  detect  any  alteration  in  the 
structure  of  the  arachnoid,  or  of  the  corresponding  cerebral 
substance.  We  may  also  observe,  that  the  effusion  was  ex- 
tremely slight  in  cases  of  sudden  death,  favoring  the  supposi- 
tion that  in  the  majority  of  instances  it  was  principally  pro- 
duced during  the  last  struggle. 

Except  in  one  of  the  cases  in  which  the  fluid  was  turbid, 
we  have  not  observed  any  characteristic  symptoms. 

204.  We  have  seen  three  times,  in  the  septum  lucidum, 
about  a  spoonful  and  a  half  of  limpid,  serous  fluid,  and  in 
these  cases  the  subarachnoidean  infiltration,  and  the  effiasion  of 
fluid  into  the  lateral  ventricles  were  proportionably  considera- 
ble, and  had  attained  the  limits  we  have  mentioned  above. 
The  parietes  of  the  septum  were  firmer  than  usual,  and  the 
arachnoid  lining  them  seemed  thickened. 

205.  The  cerebral  substance  presented  various  alterations. 
Fourteen  times  out  of  ahundred  and  one,  it  was  more  or  less 
injected.  In  five  it  was  much  softer  than  natural,  and  in  one 
it  presented  the  consistence  of  the  brain  of  a  new-born  infant. 
In  a  sixth  case  the  softening  was  bounded  to  the  left  hemi- 
sphere.    In  these  different  examples  the  duration  of  phthisis 


142  PATHOLOGICAL    ANATOMY. BRAIN  ;  [Parti, 

varied  from  seven  months  to  five  years.  We  have  six  times 
observed  the  pulpy  softening  either  of  the  fornix,  septum 
lucidùm,  or  the  corpora  striata  (Obs.  2,  7,  15,  25,  26),  and, 
with  the  exception  of  the  latter,  without  any  change  in  the 
color  of  the  softened  tissue. 

IN    PATIENTS    WHO    DIED    OF    OTHER    DISEASES. 

206.  These  different  modifications  of  the  brain  and  its 
membranes  were  not  pecuhar  to  phthisis.  We  have  encoun- 
tered them  after  a  variety  of  other  diseases.  The  granula- 
tions of  the  arachnoid  and  lacerations  of  the  dura  mater  were 
nearly  equally  frequent  as  in  phthisis.  In  one  hundred  and 
fifteen  cases,  excluding  apoplexies,  softening  of  the  brain,  and 
typhus,  there  were  sixteen  examples  of  a  slight  clear  or  turbid 
serous  effusion  over  the  upper  portion  of  the  arachnoid.  This 
effusion  was  rather  more  frequent  after  chronic  than  acute  dis- 
eases. Nine  times  out  of  an  equal  number  of  cases,  we  have 
remarked  a  more  or  less  extensive  thickening  and  opacity  of 
the  superior  portion  of  the  arachnoid.  Four  times  there  were 
some  fragments  of  thin,  soft,  and  yellowish  false  membranes- 
The  subarachnoidean  infiltration  was  present  in  two  fifths  of 
the  cases,  and  quite  as  much  in  quantity  in  fatal  and  prolonged 
acute  affections,  as  in  those  more  essentially  chronic,  as  in 
cancer,  for  example.  The  pia  mater  was  more  or  less  thick- 
ened, red  and  injected  fourteen  times  ;  an  almost  similar  pro- 
portion to  that  of  phthisis,  but  much  less  frequently  so  than  in 
cerebral  diseases  or  typhus,  in  the  proportion  of  two  to  seven. 
In  these  various  circumstances  the  brain  was  more  or  less 
injected;  effusion  into  the  lateral  ventricles  was  very  fre- 
quent ;  we  have  remarked  it  ninety-two  times,  in  different 
degrees,  within  the  limits  mentioned  for  phthisis,   and  it  was 


Chap.   10.]  HYDATIDS    AND    TUBERCLES.  143 

almost  always  proportionate  to  the  subarachnoidean  infiltration. 
In  cases  of  sudden  death  the  quantity  of  effused  fluid  was 
hardly  equivalent  to  two  or  three  cofFee-cup  spoonsful,  which 
fact  seems  to  confirm  what  we  have  previously  stated  in  relation 
to  the  period  at  which  this  effusion  seems  to  take  place  in  the 
majority  of  instances  (203).  In  fifteen  cases  the  consistence 
of  the  brain  was  remarkably  diminished,  although  less  so  than 
in  those  instances  of  phthisis  already  mentioned.  Two  only 
were  acute  cases  ;  and  as  the  number  of  the  latter,  compared 
with  chronic  diseases,  was  as  forty-five  to  seventy,  we  may 
conclude  that  softening  of  the  cerebral  substance  is  chiefly 
confined  to  protracted  cases.  Lastly,  we  have  observed  six 
examples  of  partial  and  almost  pulpy  softening  of  the  brain, 
all  subsequent  to  chronic  affections. 

Thus  whether  the  softening  of  the  brain  was  either  general 
and  slight  in  amount,  or  partial  and  pulpy,  it  was  almost  ex- 
clusively confined  to  chronic  cases,  from  which  coincidence 
we  may  suspect  that  both  these  species  of  softening  are  some- 
times analogous  in  their  nature. 

The  morbid  changes  observed  in  the  brain,  and  parts  con- 
nected with  it,  are  then  equally  common  after  phthisis  and 
other  chronic  affections.  Many  of  them  frequently  existed 
after  prolonged  acute  diseases  ;  only  varying  in  their  relative 
proportion. 

207.  The  only  lesions  we  have  remarked  exclusively  in 
the  brain  of  phthisical  patients,  are  hydatids  and  tubercles. 
We  do  not  consider  hydatids  as  peculiar  to  phthisis,  but 
from  what  has  been  hitherto  observed,  we  are  inclined  to  be- 
lieve that  this  is  the  fact  with  regard  to  tubercles.  We 
have  already  met  one  example  of  tubercles  in  the  medulla 
oblongata  (Obs.  6)  ;  we  will  relate  a  similar  one  relative  to 


144  PATHOLOGICAL    ANATOMY.  BRAIN  ;  [Part  I, 

the  brain  and  cerebellum,  after  having  first  detailed  the  only 
case  of  hydatids  in  the  brain  we  have  observed.* 

*  It  may  be  remarked  here,  that  our  author  relates  no  instance  of  hydatids 
in  the  lungs,  and  can  merely  infer  their  connexion  with  tubercles  from 
their  occasional  co-existence+  together.  The  fact  is  not  without  interest,  as 
indicating  a  state  of  constitution  favorable  to  both  these  productions,  and 
strengthening  the  idea  that  there  is  nothing  specific  in  phthisis,  but  that  it 
depends  on  a  generally  deteriorated  state  of  health.  The  opinions  of  Dr. 
Baron,  in  his  work  on  Tuberculous  Affections,  and  of  M.  Dupuy  in  his 
Traité  de  l'affection  Tuberculeuse,  that  hydatids  and  tubercles  are  identi- 
cal, are  too  irreconcilable  with  facts  to  merit  discussion.  They  are  very 
frequently  associated  together  in  the  pig,  which  has  probably  been  the  source 
of  the  idea  of  their  being  modifications  of  each  other.  Andral  has  only  met 
them  four  or  five  times  in  six  thousand  cases.  —  Clinique  Med.  vol.  iii.  page 
393,  —  Vide  also  Precis.  d'Jlnatomie  Pathol.,  page  408.  —  Laennec,  page 
298,  note  by  Translator  ;  also  page  373,  Op.  Cit.  —  Cowajv. 

t  1  did  not  mean  to  point  out  on  any  occasion  a  change  of  translation 
which  I  had  made,  but  on  the  present  one  I  find  it  necessary  to  deviate  from 
this  rule,  because  in  his  version  the  translator  has,  in  my  opinion,  misinter- 
preted our  author,  and  has  added  the  note  which,  were  I  to  publish  it  with- 
out comment,  would  still  farther  lead  to  error.  The  following  is  the  original 
French  of  the  paragraph  207.  "  Les  seules  altérations  que  nous  ayons  ob- 
servées exclusivement  dans  le  cerveau  des  phthisiques,  sont  des  hydatides 
et  des  tubercles.  Nous  ne  considérons  pas  les  hydatides  comme  une  lésion 
propre  à  la  phthisic,  mais  ce  qui  a  été  dit  jusqu'ici,  doit  porter  â  croire  que 
ce  caractère  appartient  aux  tubercules.  Nous  avons  déjà  vu  un  example 
de  cette  lesion  dans  la  moelle  allongée  (Obs.  6),"  &c.  Dr.  Cowan  translates 
the  passage  thus.  "  The  only  lesions  we  have  remarked  exclusively  in  the 
brain  of  phthisical  patients  are  hydatids  and  tubercles.  We  shall  not  con- 
sider hydatids  as  peculiar  to  phthisis,  but  from  what  has  hitherto  been  ob- 
served we  are  inclined  to  believe  them  intimately  connected  with  tubercles. 
We  have  already  met  with  an  example  in  the  spinal  marrow  (Obs.  6),"  &,c 
Now  if  the  reader  will  compare  the  original  with  Dr.  Cowan's  translation, 
he  will  perceive  that  not  only  has  the  translator  given  a  wrong  meaning  to 
the  passage,  but  in  so  doing  has  attributed  to  Louis  an  opinion  which  the 
words  of  the  original  by  no  means  authorise.  Louis  says  nothing  about  the 
intimate  connexion  of  tubercles  and  hydatids.  Andral,  in  five  cases  of  hy- 
datids, found  in  one  alone  tubercles  connected  with  thein.  —  Clin.  Med. 
vol.  iii.  page  403.  —  H.  I.  B. 


Chap.    10.]  HYDATIDS    AND    TUBERCLES.  145 


EIGHTH     OBSERVATION. 

A  STONE-CUTTER,  Eet.  54,  of  Spare  habit,  sober,  industrious 
and  seldom  ill,  had  been  subject  for  more  than  three  years  to 
sore  throats,  which  lasted  from  twenty-four  to  thirty-six  hours  ; 
for  a  still  longer  period  he  had  been  liable  to  slight  diarrhoea, 
coming  on  every  month,  continuing  a  day  or  two,  and  not  ac- 
companied with  colic.  Six  months  before  entering  the  hos- 
pital, he  was  suddenly  seized,  without  any  apparent  cause  or 
previous  cough,  with  hœmatemesis,  to  the  extent,  he  said,  of 
two  quarts  ;  and  some  days  after  he  passed  a  large  quantity 
by  stool.  He  had  kept  his  bed  several  days  afterwards,  and 
during  three  months  could  not  continue  his  occupations. 

Cough  and  expectoration  had  commenced  with  the  hae- 
morrhage or  shortly  afterwards  ;  rigors,  succeeded  by  heat  and 
perspirations,  had  come  on  during  the  last  two  months,  and 
since  the  same  period  the  respiration  had  been  very  laborious. 
The  appetite  had  diminished  ;  meat  was  disliked  from  the 
commencement  ;  thirst,  always  very  moderate  ;  no  pains  in 
the  chest  or  diarrhœa. 

On  the  26th  of  November,  1822,  the  day  after  his  admis- 
sion, weakness,  not  extreme  ;  no  headache  ;  intelligence, 
active  ;  respiration,  easy,  with  little  heaving  of  the  chest  ; 
imperfectly  defined  pectoriloquy  between  the  vertebral  col- 
umn and  the  supra  spinous  fossa  ;  respiration,  coarse  and  loud 
in  the  same  region,  elsewhere,  natural  ;  cough,  not  frequent  ; 
expectoration  nummulated,  surrounded  by  a  viscous  transpar- 
ent fluid  ;  some  shooting  pains  in  the  lateral  parts  of  the  chest  ; 
voice,  rough  and  discordant,  as  it   had  been  during  the  last 

T 


146  PATHOLOGICAL  ANATOMY. BRAIN;  [Parti, 

month.  Sensation  of  rawness  in  the  larynx  during  cough  or 
deglutition.  Temperature,  natural  ;  pulse,  calm,  regular,  un- 
der seventy.  Tongue  and  appetite,  natural  3  little  thirst  ;  de- 
glutition, difficult,  although  the  pharynx  and  amygdalas  were 
perfectly  healthy  ;  the  whole  of  the  abdomen  sluggish  ;  had 
one  stool  of  moderate  consistence  the  preceding  evening. 

(Decoction  of  lich.  island;  pectoral  infusion  for  drink; 
gum  potion  ;  a  fourth  of  house  allowance.  Four  ounces  of 
wine.) 

The  following  month,  slight  general  improvement  ;  he  felt 
better  and  was  free  from  rigors  ;  aphonia,  occasionally  com- 
plete.    The  appetite  increased,  and  he  had  his  food  doubled. 

From  the  24th  of  December  to  the  31st  of  January,  the 
day  preceding  his  death,  his  intellectual  faculties  remained 
unaffected,  he  slept  little,  had  no  headache,  but  became  very 
gradually  weaker. 

The  degree  of  aphonia  was  variable  ;  there  was  a  constant 
pain  immediately  above  the  thyroid  cartilage,  with  sense  of  heat, 
especially  at  night  ;  swallowing  the  saliva  caused  pain  ;  natural 
state  of  pharynx  and  amygdalae  ;  increase  of  cough  and  dys- 
pnoea during  the  first  ten  days  of  January  ;  these  diminished 
after  the  15th,  when  the  expectoration  became  more  opaque. 
At  the  same  time  there  was  a  somewhat  acute  pain  corres- 
ponding to  the  left  mamma,  without  distinct  alteration  of  the 
clearness  of  percussion  in  the  same  region.  Under  the  left 
clavicle,  to  the  extent  of  five  inches,  there  were  tracheal  res- 
piration and  gurgling  râle  ;  this  was  equally  the  case  posteri- 
orly in  the  corresponding  point,  though  over  a  less  extent  of 
surface.     On  the  right  side  there  was  a  mucous  râle. 

The  pulse  continued  slow  ;  the  rigors  returned  during  the 
evening,  followed  by  heat  and  perspirations. 

From  the  26th  to  the  28th  of  December,  violent  colic  pains, 


Chap.   10.]  HYDATIDS    AND    TUBERCLES.  147 

succeeded  by  copious  diarrhosa,  lasting  from  the  2d  to  the  10th 
of  January  ;  entirely  ceasing  from  the  16th  to  17th,  and  after- 
wards reduced  to  two  or  three  stools  in  the  four  and  twenty 
hours. 

Tongue,  constantly  natural  ;  epigastric  region,  free  from 
pain  ]  diminution  of  appetite  from  the  commencement  of 
diarrhœa. 

31st.  Sudden  increase  of  debility;  face,  very  palej  he 
complained  of  a  very  unpleasant  feeling  of  weakness  in  the 
epigastrium  ;  on  percussion,  under  left  clavicle  for  three  inches, 
perfect  flatness  ;  sputa,  greenish  and  greyish,  with  a  slight 
pink  tinge  on  edges,  and  of  the  consistence  of  pea-soup. 
Pulse,  calm  and  regular  ',  there  was  slight  delirium  during  the 
night,  and  death  took  place  at  three,  a.  m. 

Food  was  given  proportionately  to  the  appetite  and  state  of 
the  alimentary  canal .  At  the  commencement  of  the  diarrhoea, 
rice  water,  sweetened  with  quince  syrup,  was  prescribed  ; 
afterwards,  the  diascordium,  with  a  grain  of  opium,  in  eight 
ounces  of  infusion  of  cachou,  as  soon  as  it  became  consider- 
able. 

Opening  of  the  corpse  twenty-nine  hours  after  death. 

Exterior.  —  Nothing  remarkable. 

Head.  —  Strong  adhesions  of  the  dura  mater  to  the  sagittal 
suture.  No  infiltration  beneath  the  arachnoid.  On  the  upper 
part  and  sides  of  the  brain,  beneath  the  pia  mater,  there  were 
observed  about  twenty  small  vesicles,  elevated  about  a  line  or 
a  hne  and  a  half  above  the  level  of  the  convolutions,  while 
the  rest  of  their  substance  was  imbedded  in  the  cerebrum, 
which  was  perfectly  healthy  immediately  around  them.  Their 
form  was  rounded,  and  they  were  of  different  dimensions. 
Three  among  them  equalled  in  size  a  common  hazel-nut  ;  they 


148  PATHOLOGICAL    ANATOMY. BRAIN;  [Parti, 

■were  smooth  exteriorly,  and  each  had  a  pedicle,  from  which 
a  \Yhitish  and  opaque  membrane,  only  partially  covering  the 
hydatid,  seemed  to  radiate.  The  latter  was  formed  by  a  soft, 
thin  membrane,  containing  a  fluid  which  gave  a  cloudy  ap- 
pearance to  water.  The  other  hydatids  had  the  same  struc- 
ture, but  were  a  little  larger,  more  opaque,  and  their  surfaces 
were  more  or  less  rough,  giving  them  somewhat  the  aspect  of 
a  mulberry.  Brain,  much  injected  ;  lateral  ventricles,  pons 
varolii  and  cerebellum,  natural. 

Neck.  — Total  destruction  of  the  mucous  membrane  on  the 
laryngeal  surface  of  the  epiglottis  ;  the  edges  of  the  ulceration 
ratherthick,  indurated  and  whitish;  the  bottom,  rugged  and  pink 
colored.  Two  small,  superficial  ulcerations  above  the  supe- 
rior vocal  cords,  of  which  the  left  was  almost  entirely  destroy- 
ed ;  the  circumference  of  the  ulcer  was  greyish,  and  indurated 
like  lard.  Mucous  membrane  of  the  trachea,  red  and  shghtly 
thickened  inferiorly  ;  that  of  the  bronchia  still  redder  ;  both 
were  free  from  ulceration. 

Chest.  — On  the  left  side,  rather  less  than  a  quart  of  dirty 
red-colored  fluid,  enclosed  by  a  false  membrane,  which  covered 
the  lung  ;  diaphragmatic  and  costal  pleurae  of  a  florid  red  inter- 
nally, and  about  half  a  line  thick.  At  the  summit  of  the  upper 
lobe  was  a  large  excavation,  lined  by  a  semi-cartilaginous  false 
membrane,  reposing  either  on  healthy  pulmonary  tissue,  tuber- 
cles, or  small  melanotic  masses.  In  the  rest  of  its  extent,  it  pre- 
sented a  number  of  small  and  generally  incompletely  emptied 
cavities.  The  lower  lobe  contained  numerous  grey  granula- 
tions, without  tubercles  or  excavations.  On  the  right  side, 
(with  the  exception  of  the  effusion  and  false  membrane,  which 
did  not  exist),  the  state  of  the  lung  was  very  similar  to,  though 
less  extensively  disorganized,  than  the  left.  Heart,  sound  ;  the 
aorta,  below  cœliac  trunk,  presented  numerous  cartilaginous 


Chap.   10.]  HYDATIDS     AND    TUBERCLES.  149 

and  osseous  patches.  The  femoral  arteries  presented  circular 
and  rather  parallel  osseous  bands,  slightly  prominent  internally. 
Abdomen. — Gastric  mucous  membrane  of  alight  pink  color 
in  some  points,  a  little  softened  in  the  great  cul-de-sac,  but 
every  where  of  natural  thickness.  To  the  left  of  the  cardiac 
orifice  there  was  an  ulceration  of  half  an  inch  in  diameter, 
with  irregular,  slanting  edges,  lined  by  the  uneven  and  thick- 
ened submucous  tissue.  The  mucous  membrane  of  the  duo- 
denum, slightly  greyish,  with  no  other  lesion.  That  of  the 
small  intestine  was  natural,  with  the  exception  of  two  small 
ulcerations,  offering  some  semi-transparent  miliary  tubercles 
at  their  surface.  In  the  large  intestine  it  was  soft  as  mucus, 
and  in  many  points  of  a  violet  red.  In  the  rectum  there  were 
ten  small,  submucous  abscesses,  of  the  size  of  a  pea,  and  eight 
ulcerations  of  similar  dimensions.  The  spleen  was  softened. 
The  other  viscera  of  the  abdomen  were  healthy. 

208.  Hydatids  of  the  brain  are  extremely  rare  ;  so  much 
so,  that  at  the  period  of  our  taking  the  last  observation,  M. 
Chomel  had  not  met  a  single  example.  They  were  never 
entirely  enveloped  by  the  cerebral  substance.  They  pro- 
truded under  the  pia  mater,  in  which,  no  doubt,  they  origi- 
nated. The  healthy  condition  of  the  cerebral  substance  im- 
mediately in  contact  with  them  seems  to  indicate  the  slowness 
of  their  increase,  and  the  total  absence  of  all  cerebral  symp- 
toms is  also  in  favor  of  this  idea.  The  patient  did  not 
experience  the  slightest  cephalalgia. 

With  the  exception  of  hydatids,  all  the  other  alterations, 
however  numerous,  gave  rise  to  corresponding  symptoms. 
The  aphonia  was  caused  by  the  ulcerations  in  the  larynx. 
The  pain  beneath  the  thyroid  cartilage  and  the  dysphagia, 
(the  pharynx  and  tonsils  being  perfectly  healthy,)   pointed 


150  PATHOLOGICAL    ANATOMY. BRAIN;  [Parti, 

out,  as  we  shall  see  (289),  or  at  least  gave  reason  to  suspect, 
the  ulceration  of  the  epiglottis.  The  attack  of  pleuritis  was 
accompanied  with  a  pretty  acute  pain  in  the  left  side  of  chest. 
Pains  equally  acute  came  on  with  the  diarrhoea,  which,  though 
only  present  eighteen  days,  had  produced  the  pulpy  softening, 
and  perhaps  complete  disorganization  of  the  mucous  membrane 
of  the  colon  !  In  the  midst  of  all  these  disorders,  and  at  the 
commencement  of  two  severe  inflammations,  which  run  their 
course  rapidly,  viz.,  pleuritis  and  enteritis,  it  is  worthy  of 
remark,  that  the  pulse  continued  calm,  and  the  temperature  was 
not  elevated  !  How  numerous  are  similar  facts,  which  prove 
that  it  is  especially  to  the  investigation  of  local  symptoms  that 
the  physician  ought  to  direct  his  attention,  in  order  to  make  a 
correct  diagnosis  ! 

Let  us  also  remark,  that  the  disease  commenced  by  a  copi- 
ous haemorrhage  preceding  the  cough  and  expectoration.  Not- 
withstanding the  assertions  of  the  patient  of  his  having  vomited 
the  blood,  and  although  intestinal  haemorrhage  succeeded  in  a 
few  days,  it  is  scarcely  possible  to  doubt  that  both  were  de- 
pending upon  the  lungs  ;  first,  because  haemoptysis  is  fre- 
quently the  precursory  symptom  of  phthisis  ;  and  it  is  some- 
times so  abundant,  that  patients  both  affirm  and  believe  that 
blood  has  been  vomited,  although  this  has  not  been  the  fact  ; 
secondly,  because  the  state  of  the  stomach  was  not  such  as 
causes  haematemesis  ;  and  because  every  thing  else  is  in  favor 
of  the  idea,  that  during  the  haemorrhage,  and  long  after,  this 
viscus  was  healthy.  Lastly,  because  the  biuod  voided  by 
stool  could  very  easily  have  proceeded  from  the  lungs,  some 
having  passed  into  the  stomach  by  deglutition. 


Chap.   10.]  TUBERCULOUS    MASSES    IN    IT.  151 


NINTH    OBSERVATION. 

S09.  A  YOUNG  girl,  set.  19,  with  active  intellect  and  reten- 
tive memory,  born  of  healthy  parents,  but  herself  of  a  feeble 
constitution,  combining  the  lymphatic  with  the  sanguineous 
temperament,  and  not  subject  to  colds,  entered  the  hospital 
of  La  Charité,  October  1st,  1822.  Her  illness,  dating  seven 
months,  had  commenced  by  rigors,  dyspnoea,  loss  of  appetite, 
thirst,  and  a  pulsating  pain  in  the  epigastric  region.  During 
five  months,  the  rigors  occurred  daily  without  interruption, 
but  were  afterwards  less  regular.  The  epigastric  pain  was 
almost  constant  ;  loss  of  appetite  more  or  less  complete  ; 
thirst,  variable  in  intensity  ;  neither  nausea  nor  vomiting.  The 
dyspnœa  had  gradually  increased  ;  but  cough  and  expectora- 
tion had  only  existed  the  last  three  weeJcs  ;  and,  twelve  days 
before  entering  the  hospital,  she  had  been  attacked  with  a 
slight  hsemoptysis.  The  catamenia  had  been  suppressed  two 
months  before  her  present  illness,  and  had  not  since  reap- 
peared; at  each  menstrual  period  she  was  attacked  with 
a  headache,  much  more  violent  than  usual  at  those  periods. 
Bowels  had  been  always  regular,  and  emaciation  had  com- 
menced with  the  first  symptoms. 

Oct.  1st.  Intelligence,  perfect  ;  no  headache  ;  respiration, 
rather  accelerated  ;  coughs  little  ;  sputa,  flocculent  ;  percus- 
sion, every  where  sonorous  ;  imperfect  pectoriloquy  between 
the  shoulders  ;  no  thoracic  pains  ;  pulse,  one  hundred  ;  ap- 
petite, moderate  ;  slight  thirst  ;  tongue,  rather  red  ;  cervical 
glands,  enlarged  and  painful  ;  a  tumor  in  umbilical  region, 
rather  to  the  right,  without  tenderness,  of  the  size  of  an  ordi- 
nary apple  ;  no  pain  in  the  epigastrium  ;  bowels,  constipated. 


152  PATHOLOGICAL  ANATOMY.  BRAIN  ;  [Part  I, 

(Fifteen  leeches  to  labia  ;  gum  potion  j  pectoral  infusion 
and  soups). 

On  the  following  days  the  appetite  was  much  increased, 
and  a  fresh  application  of  leeches  was  prescribed,  on  account  of 
some  streaks  of  blood  in  expectoration. 

10th.  Patient  complained  of  acute  pains  in  the  right  axilla, 
where  the  glands  were  much  enlarged.  Drowsiness  ;  face, 
injected  and  turgid. 

20th  to  25th.  Intense  headache  ;  face,  more  flushed  than 
usual  ;  sudden  flashes  of  heat  more  frequent,  and  more  incon- 
venient. 

25th.  Twelve  leeches  to  labia  without  any  relief;  no  sen- 
sible change  in  cough  or  expectoration  ;  distinct  pectoriloquy 
between  the  shoulders  ;  respiration,  tracheal  under  clavicles  j 
the  abdominal  tumor  seemed  increased. 

Nov.  4th.  For  the  first  time  some  liquid  stools,  and  for  the 
last  three  days  nocturnal  perspirations  ;  tumor  in  abdomen, 
painful. 

(V.  S.  ad  g  viij). 

From  this  date  to  the  26th  of  December,  the  day  of  her 
death,  the  face  was  of  a  deep  red  color,  which  afterwards 
changed  to  a  livid  tint. 

Much  drowsiness  at  times,  and  at  other  moments  inability 
to  sleep  ;  headache,  nearly  constant.  The  debility  rapidly 
increased,  and  the  patient  was  wholly  confined  to  her  bed. 

The  sputa,  occasionally  viscous  and  spumous,  became 
opaque  and  streaked  with  blood,  twenty-four  hours  before 
death.     Dyspnœa,  more  and  more  urgent. 

Dec.  1st.  Complained  of  burning  sensation  in  the  course  of 
the  trachea,  which  sensation  was  experienced  often  after- 
wards. The  rigors,  which  had  returned  almost  daily  since  her 
entering  the  hospital,  persisted.     Copious  perspirations  during 


Chap.   10.]  TUBERCULOUS    MASSES    IN    IT. 


153 


sleep,  which  did  not  yield  to  successively  increasing  doses  of 
acetate  of  lead. 

The  diarrhœa,  with  occasional  colics,  continued.  Com- 
plete anorexia  from  the  1st  of  December  ;  no  nausea,  vomit- 
ing, or  distinct  epigastric  pains.  Thirst,  at  last,  very  urgent  ; 
and  on  the  23d,  the  tongue,  which  had  been  whitish  or  slight- 
ly red  for  some  time  previously,  assumed  a  dull  red  color, 
and  was  covered  by  a  number  of  small,  white,  opaque,  almost 
miliary  spots. 

From  the  commencement  of  the  diarrhoea,  the  patient  was 
treated  by  rice  water,  sweetened  with  quince  syrup.  Small 
doses  of  syrup  of  poppies  were  prescribed  for  the  restlessness, 
but  with  little  success.  The  food  consisted  of  some  rice 
creams,  and  occasionally  broth. 

Opening  of  the  corpse  thirty-three  hours  after  death. 

ExTERioK.  —  Integuments  mottled;  extreme  emaciation. 

Head.  —  At  the  posterior  part  of  the  right  hemisphere, 
the  arachnoid  was  adherent  to  the  dura  mater,  in  a  point  cor- 
responding to  a  nodulated  tumor,  developed  near  the  surface 
of  the  brain,  and  about  the  size  of  a  common  nut.  It  was  of  a 
dull  greenish-yellow  color,  firm,  in  every  respect  tuberculous, 
and  not  encysted.  Round  it  the  cerebral  substance  was 
healthy.  Between  the  upper  surface  and  lateral  ventricle 
of  the  same  hemisphere,  five  siniilar  tubercles  existed.  On 
the  left  side  there  were  four,  and  one  of  them  occupied  the 
posterior  and  inferior  part  of  the  opticus  thalamus.  At  the 
base  of  the  posterior  lobe  of  the  same  side,  a  portion  of  the 
cerebral  structure  was  transformed  into  tuberculous  matter, 
under  the  form  of  a  layer  four  lines  thick,  and  an  inch  and  a 
half  in  extent.  It  was  partially  adherent  to  the  dura  mater, 
u 


154  PATHOLOGICAL    ANATOMY. BRAIN  ;         [Part  I, 

which  lies  above  the  cerebellum,  the  corresponding  layer  of 
which  had  undergone  the  same  alteration.  Lastly,  at  the 
inferior  part  of  the  left  hemisphere  of  the  cerebellum,  a  non- 
encysted  tubercle,  about  the  size  of  a  nut,  extended  to  the 
spinal  marrow,  and  even  to  a  small  degree,  into  its  substance. 

Neck.  — -  The  cervical  glands  were  very  voluminous,  com- 
pletely transformed  into  crude  tuberculous  matter;  larynx  and 
epiglottis,  natural  ;  mucous  membrane  of  the  trachea,  intense- 
ly red,  especially  posteriorly. 

Chest.  —  A  mass  of  indurated,  tuberculous,  lymphatic 
glands,  about  the  size  of  a  goose's  egg,  in  right  axilla.  Uni- 
versal cellular  adhesions  of  both  lungs.  An  extensive  an- 
fractuous cavity  in  the  summit  of  the  left  lung,  containing  a 
small  quantity  of  red  fluid,  and  traversed  by  numerous  bands 
or  intersections  of  grey  substance.  The  parietes  were  formed 
by  a  semi-cartilaginous  false  membrane,  lying  upon  tubercles 
and  the  grey,  semi-transparent  matter.  The  remainder  of  the 
upper  lobe  was  almost  entirely  transformed  into  the  grey  or 
tuberculous  matter,  and  into  small  excavations,  between  which 
the  pulmonary  parenchyma  was  of  a  deep  red  color.  Pretty 
numerous  crude  tubercles  in  the  inferior  lobe.  Similar  lesions 
in  the  right  lung,  but  less  extensive  ;  two  softened  tubercles 
protruded  on  the  surface.  Bronchia,  of  a  bright  red  color, 
communicating  freely  with  the  excavations.  Heart,  rather 
small,  but  healthy  ;  aorta,  natural. 

Abdomen.  —  About  a  quart  of  limpid  serum  in  the  perito- 
neal cavity.  The  liver,  rather  larger  than  usual,  presented 
twelve  small  cysts,  two  to  three  lines  in  diameter,  and  filled 
by  a  greenish,  pulpy  substance  ;  their  parietes  were  very  thin, 
greyish,  and  easily  torn.  Parenchyma,  healthy  ;  bile  in  gall- 
bladder, black  and  thick  like  treacle.  Mucous  membrane  of 
the  stomach,  red,  mamillated,  and  of  good  consistence  on  the 


Chap.    10.]  TUBERCULOUS    MASSES    IN    IT.  155 

anterior  surface,  to  the  extent  of  three  inches  ;  it  was  pale 
elsewhere,  and  very  soft  in  different  portions  of  the  great  cul- 
de-sac.  There  were  in  the  duodenum  ten  small  ulcerations, 
from  a  line  to  a  line  and  a  half  in  diameter.  Others  similar 
to  these  were  dispersed  through  the  whole  length  of  the  small 
intestine,  either  occupying  the  patches,  or  situated  in  their 
intervals.  Their  edges  were  rather  prominent,  and  the  bot- 
tom lined  by  the  thickened  submucous  layer.  The  mucous 
membrane  of  the  large  intestine  was  red  in  the  ascending 
colon,  which  also  offered  two  small,  superficial  ulcerations  ; 
elsewhere  it  was  pale,  and  throughout  as  soft  as  mucus.  The 
mesenteric  glands  were  voluminous,  red,  and  in  part  tuber- 
culous. The  tumor,  felt  in  the  umbilical  region,  was  situated 
above  the  pancreas,  equal  in  size  to  the  shut  hand,  formed  by 
the  re-union  of  a  large  number  of  tuberculated,  lymphatic 
glands,  connected  inferjorly  with  the  lumbar  glands,  which 
were  similarly  affected.  Not  one  was  softened.  The  spleen, 
of  ordinary  dimensions,  contained  numerous  round  tubercles, 
varying  from  the  size  of  hemp-seed  to  that  of  a  small  nut. 
The  other  viscera  of  the  abdomen  were  healthy. 

210.  The  most  striking  fact  in  this  observation  is  not  the 
development  of  tubercles  in  the  brain  and  cerebellum,  but 
their  simultaneous  existence  in  a  variety  of  other  organs,  as 
the  lungs,  neck,  right  axilla,  mesentery,  loins  and  spleen  ; 
and,  more  especially,  their  equal  development  every  where, 
with  the  exception  of  the  lungs. 

We  do  not  see  how  any  explanation  of  these  facts  can  be 
attempted,  unless  we  admit  the  action  of  one  and  the  same 
cause  upon  all  these  organs  at  the  same  time.  For  if  the 
ulcerations  of  the  small  intestine  were  the  only  cause  of  the 
conversion  of  the  mesenteric  glands  into  tubercles,  how  do  we 


156  PATHOLOGICAL  ANATOMY.  BRAIN.  [Part  1, 

explain  those  of  the  brain,  axilla,  or  spleen  ?  How  do  we  ao- 
count  for  the  similar  state  of  the  tuberculous  matter,  every 
where  unsoftened,  if  the  causes  of  its  production  were  differ- 
ent, and  the  time  of  its  deposition  not  identical  ?  Under  no 
hypothesis  can  the  state  of  the  small  intestine  explain  the 
tuberculous  transformation  of  the  glands  situated  above  the 
pancreas,  since  the  tumor  existed  previous  to  the  entrance  of 
patient  into  the  hospital,  long  before  the  commencement  of 
the  diarrhœa,  and,  consequently,  at  a  period  when  the  raucous 
membrane  of  the  small  intestine  was  still  healthy.  And  let 
not  this  be  considered  mere  conjecture,  for  the  inconsiderable 
size  and  structure  of  the  ulcerations  of  the  small  intestine  are 
sufficient  proofs  that  they  were  recent. 

Let  us  also  remark  that  the  tuberculous  matter  was  more  ad- 
vanced in  the  lungs  than  elsewhere,  which,  in  this  instance,  as 
well  as  in  others,  favors  the  idea  that,  with  respect  to  tubercles, 
the  whole  economy  is,  as  it  were,  in  subjection  to  the  lungs. 

211.  The  fewness  of  the  symptoms  caused  by  the  tuber- 
cles in  the  brain  is  also  worthy  of  attention.  The  increase  of 
headache  at  the  menstrual  period,  and  the  sudden  flushings  of 
the  face,  can  scarcely  be  ascribed  to  the  presence  of  tubercles 
in  tlie  brain,  since  the  pain  complained  of  in  the  cervical 
glands  might  have  been  their  cause,  or  at  least  have  had  some 
influence  upon  their  production.  If  "we  reflect  also,  that  the 
intellectual  faculties  and  the  voluntary  movements  were  never 
affectefl,  the  symptoms  we  have  mentioned,  if  depending  on 
the  brain,  were  at  least  very  insignificant.  It  will  at  the  same 
time  be  granted,  that  if  tubercles  and  hydatids  can  be  devel- 
oped in  so  latent  a  manner  in  the  brain,  the  same  may  take 
place  in  the  lungs  ;  and  we  ought  not  to  feel  surprised  that 
phthisis  may  remain  concealed,  as  it  were,  during  a  variable 
period  of  time.     This  proposition,  which   we  shall  hereafter 


Chap.  10.]  SUMMARY  ;  secondary  affections.      157 

strengthen  by  numerous  examples,  is  realized  in  the  case  be- 
fore us,  for  from  the  moment  of  the  entrance  of  the  patient 
into  the  hospital,  pectoriloquy  could  be  detected,  while  the 
cough  had  only  existed  a  few  days  !  Most  probably  there  were 
pulmonary  tubercles  from  the  commencement,  that  is,  as  soon 
as  the  dyspnoea  and  fever  were  manifested,  for  the  most  im- 
portant chronic  alteration  of  the  viscera,  viz.  that  of  the  lungs, 
can  alone  explain  the  first  symptoms. 


SUMMARY. 

212.  It  is  sufSciently  obvious,  from  what  has  preceded, 
that  the  pulmonary  organs  were  not  the  only  ones  whose  func- 
tions were  impeded,  but  that  others  were  the  seat  of  exten- 
sive morbid  alterations  sufficient  alone  to  produce  death  ;  and 
that  almost  all  contributed  to  hasten  the  final  catastrophe. 
Their  rapid  survey  will  give  a  clearer  idea  of  the  whole. 

Tubercles  and  pulmonary  excavations  were  in  one  tenth  of 
the  cases  connected  either  with  recent  inflammation  of  a  por- 
tion of  one  or  both  lungs,  of  the  pleurœ,  or  with  the  effusion 
of  a  notable  quantity  of  limpid  fluid  into  the  thoracic  cavity. 

The  trachea  presented  ulcerations,  often  of  very  great  size, 
in  rather  less  than  one  third  of  our  observations.  Its  mucous 
membrane  was  merely  reddened,  sometimes  slightly  softened, 
or  thickened  in  one  fifth. 

The  larynx  was  ulcerated  in  rather  more  than  one  fifth,  and 
the  epiglottis  in  a  nearly  similar  proportion. 

The  pericardium  contained  a  marked  quantity  of  very  clear 
fluid  in  one  tenth  of  the  cases,  and  presented  traces  of  chronic 


158  PATHOLOGICAL  ANATOMY.  SUMMARY  ;       [Part  1, 

or  recent  inflammation  in  many  others.  The  heart  was  rather 
frequently  softened  ;  the  aorta,  red  in  the  majority  of  young 
patients,  and  its  structure  more  or  less  modified  after  the  age 
of  forty. 

In  one  twelfth  of  the  patients  the  stomach  was  very  much 
dilated,  and  situated  lower  down  than  natural.  Its  mucous 
membrane  was  red,  sometimes  mamillated,  a  little  softened,  and 
thickened  anteriorly,  nearly  in  the  same  proportion.  In  one 
fifth  it  was  more  or  less  extensively  softened  and  thinned.  We 
found  it  in  the  same  proportion  very  red,  softened,  and  some- 
times thickened  in  the  great  cul-de-sac  ;  it  was  ulcerated,  of 
a  more  or  less  greyish  tint,  and  mamillated  in  many  others, 
&;c.  ;  so  that  it  was  only  healthy  in  one  fifth  of  our  examples. 

In  the  small  intestine  there  were  ulcerations,  varying  in 
number  and  extent,  in  five  sixths  of  the  patients.  They  were 
nearly  as  frequent  in  the  large  intestine,  of  which  the  mucous 
membrane,  often  red,  and  in  one  half  of  the  cases  thickened, 
was  either  throughout  its  whole  extent,  or  only  over  a  part,  of 
the  consistence  of  mucus,  so  that  we  have  only  seen  it  per- 
fectly healthy  three  times. 

The  tuberculization  of  lymphatic  glands  was  less  frequent 
in  the  neck,  loins,  mesocolon,  and  axilla  than  in  the  mesen- 
tery, where  it  existed  in  various  degrees,  in  one  fourth  of  the 
cases. 

The  liver  had  become  adipous  in  one  third  of  the  examples. 
The  parietes  of  the  gall-bladder  were  occasionally  thickened 
and  ulcerated,  and  when  this  was  the  case,  as  also  under  some 
other  circumstances,  it  contained  calculi. 

The  spleen  was  softened,  and  under  or  above  its  natural 
volume  in  a  great  number  of  instances.  It  was  tuberculated 
in  one  sixth. 


Chap.   10.]  SECONDARY  AFFECTIONS.  159 

The  last  alteration  was  nearly  equally  frequent  in  the  kid- 
neys, where  we  sometimes  discovered  cysts. 

In  many  individuals  the  prostate  was  tuberculated  ;  in  one 
of  these  there  was  an  example  of  tubercular  exhalation  in  the 
interior  of  the  vesiculse  séminales  and  vasa  deferentia.  We 
have  once  seen  the  internal  surface  of  the  uterus  converted 
into  tuberculous  matter. 

From  one  to  six  quarts  of  clear  serous  effusion  in  the  abdo- 
men existed  in  one  fourth,  and  a  small  quintity  of  pus,  "or 
some  false  membrane  in  the  pelvis  in  four  others.  We  have 
seen  several  cases  of  tubercular  peritonitis.  In  one  the  great 
omentum  and  mesocolon  presented  a  mixture  of  grey,  bluish, 
semi-transparent  and  tuberculous  substance. 

The  cerebral  arachnoid  was  often  partially  thickened,  pre- 
senting more  or  less  numerous  granulations  in  its  upper  por- 
tion, especially  near  the  falx.  In  two  cases  it  was  lined  by  a 
yellowish  and  soft  false  membrane.  The  tissue  uniting  it  to 
the  pia  mater  was  infihrated,  and  the  ventricles  distended  by 
a  very  appreciable  quantity  of  serum  in  three  fourths  of  our 
examples.  The  same  fluid  was  found  in  the  occipital  fossae, 
but  less  frequently  and  not  so  abundantly.  In  one  seventh  the 
brain  was  injected  ;  in  one  twentieth  its  consistence  was  gen- 
erally diminished,  and  in  one  instance  to  a  remarkable  extent. 
Its  partial  and  pulpy  softening  was  observed  in  the  same  pro- 
portion. 

All  the  serous  membranes,  the  arachnoid,  pericardium, 
pleurae  and  peritoneum,  were  thus  very  frequently  the  seat  of 
effusion  ;  and  it  was  in  the  lateral  ventricles  of  the  brain  that 
this  was  most  generally  observed,  at  least  when  copious. 

The  same  membranes  were  also  liable  to  acute  inflamma- 
tion, coming  on  towards  the  close  of  life,  and  this  was  most 
frequently  the  case  with  the  pleurae. 


160  PATHOLOGICAL    ANATOlViy. SUMMARY;      [Parti, 

la  some  instances,  many  of  the  morbid  states  just  glanced 
at,  as  the  softening  and  thinning  of  the  gastric  mucous  mem- 
brane and  the  ulcerations  of  the  intestines,  were  sufficient  of 
themselves  to  have  caused  death,  independently  of  the  lungs. 
However  combined  with  them,  there  were  other  lesions.  The 
seventh  observation  furnishes  a  case  in  which  all  the  viscera, 
with  the  exception  of  the  kidneys,  were  more  or  less  ex- 
tensively affected. 

The  period  to  which  the  commencement  of  these  different 
alterations  could  be  referred,  was  very  variable.  Pneumonia, 
pleuritis,  softening  and  redness  of  the  great  cul-de-sac  of  the 
stomach,  pulpy  softening  of  the  colon,  peritonitis,  arachnitis, 
partial  and  pulpy  softening  of  the  brain  originated  a  few  days 
previous  to  death.  The  greater  part  were  the  result  of  in- 
flammation, plainly  proving  that  weakness,  so  far  from  being 
an  obstacle,  is,  on  the  contrary,  favorable  to  inflammatory 
action.  The  other  alterations  dated  much  further  back, 
sometimes  to  the  commencement  of  phthisis,  as,  for  instance, 
softening  with  diminished  thickness  of  the  mucous  membrane 
of  the  stomach  ;  and  in  some  cases,  the  large  intestinal 
ulcerations  (Obs.  4). 

These  various  morbid  changes  presented  a  two-fold  char- 
acter ;  some  were  peculiar  to  phthisis,  others  were  not  so  ; 
but  were  present  in  different  degrees,  after  a  variety  of  other 
chronic  affections. 

Among  the  first  class  may  be  enumerated  ulcerations  of  the 
larynx,  and  more  especially  of  the  trachea  and  epiglottis  ; 
ulcerations  of  both  intestines  (principally  of  the  small)  ;  the 
adipous  state  of  the  liver  :  so  that  by  seeing  an  ulceration  in 
either  of  the  organs  mentioned.  Sec,  we  could  be  able  to 
assert,  independently  of  all  farther  investigation,  that  the 
patient  had  died  of  phthisis. 


Chap.   10.]  SECONDARY    AFFECTIONS.  l6l 

These  ulcerations,  wherever  they  were  situated,  in  their 
mode  of  production  presented  many  points  of  resemblance. 
When  the  mucous  membrane  was  destroyed,  the  submucous 
layer  gradually  thickened  and  became  uneven  ;  after  a  time 
it  ulcerated,  and  then  the  muscular  coat  in  its  turn  began  to 
thicken  :  this  was,  like  the  former,  subsequently  destroyed 
(though  its  total  destruction  was  extremely  rare)  ;  so  that  in 
proportion  as  one  of  the  coats  of  the  intestine  became  ulcer- 
ated, the  succeeding  one  thickened,  and  by  thus  opposing 
greater  resistance  to  its  destruction,  protracted  the  fatal  termi- 
nation. 

The  last  morbid  alteration  was  peculiar  to  phthisis,  viz., 
tubercles,  wherever  they  might  be  found.  We  have  never  ob- 
served them  in  a  single  instance  in  any  organ,  without  their 
existence  in  the  lungs  ;  so  that  their  presence  in  these  last 
viscera  seems  a  necessary  condition  for  their  development  in 
other  parts.  Another  fact  which  strengthens  the  idea  of  this 
dependence  is,  that  with  one  single  exception,  we  have  always 
seen  the  tuberculous  matter  more  advanced  in  the  lungs  than 
elsewhere,  and  when  tubercles  existed  at  the  same  time  in 
different  parts  of  the  body,  they  were  at  the  same  degree  of 
development;  and  it  would  be  difficult  to  conceive  of  this  uni- 
formity, in  parts  so  distant  one  from  another,  so  various  in  struc- 
ture, unless  we  admit  the  influence  of  one  and  the  same  cause, 
acting  simultaneously  on  a  great  number  of  organs  ;  thus 
making  tuberculous  deposition  quite  independent  of  those 
occasional  causes  we  are  apt  to  suppose  active  in  certain 
cases. 

As  our  object,  however,  is  not  to  support  one  opinion  more 
than  another,  we  will  remark,  that  we  have  found  one  excep- 
tion to  the  law  we  have  established.    It  was  in  a  case  of  typhus. 
w 


162  PATHOLOGICAL    ANATOMY. SUMMAKT, 

No  tubercles  existed  in  the  lungs,  and  yet  there  was  a  small 
quantity  of  tuberculous  matter  in  the  mesenteric  glands.* 

*  See  Appendix  A  by  the  Translator  for  some  valuable  remarks  upon  the 
development  of  tubercles.  —  H.  I.  B^ 


SECOND     PART 


SYMPTOMS. 


PART    II. 

SYMPTOMS. 

213.  In  this  division  of  our  work,  we  shall  successively 
describe  the  symptoms  of  phthisis,  and  those  attending  its 
different  complications,  the  variations  it  presents  in  its  pro- 
gress, when  acute  or  latent  ;  the  circumstances  attending  the 
perforation  of  the  pulmonary  parenchyma  and  sudden  deaths  ; 
after  which,  we  shall  examine  the  causes  which  are  generally 
considered  as  influencing  the  development  of  tubercles  in  the 
lungs  ;  and,  finally,  we  shall  briefly  speak  of  the  treatment. 


CHAPTER    I. 

SYMPTOMS  OF  PHTHISIS. 

214.  From  what  has  already  been  said,  it  will  be  seen  how 
rare  it  was  to  find  a  case  of  phthisis  in  which  the  morbid  altera- 
tions were  confined  to  the  lungs  ;  and  it  might  be  thought  almost 
impossible,  judging  from  the  one  hundred  and  twenty-three 
observations  we  have  collected,  to  give  the  history  of  the  dis- 
ease in  a  state  of  simplicity.  But  let  us  remark,  that  it  would 
not  be  right  to  view  many  of  the  lesions  we  have  described  in 
the  light  of  complications  ;  as,  for  instance,  the  ulcerations  of 
the  trachea,  larynx  and  epiglottis,  of  the  small  and  large  in- 


166  SYMPTOMS. GENERAL    DESCRIPTION;       [Part  II, 

testine.  and  the  adipous  transformation  of  the  hver  ;  for  these 
alterations  being  pecuHar  to  phthisis  must  be  regarded  as  a 
part' of  the  disease  itself.  We  may  also  observe  that  pleurisies, 
pneumonias,  &ic.  fee,  coming  on  in  the  last  periods  of  the 
affection,  do  not  interfere  with  its  simplicity.  We  have  thus 
greater  latitude  for  forming  our  conclusions  than  might  at  first 
be  anticipated  ;  and  we  are  enabled  to  found  a  general  de- 
scription of  the  disease  upon  a  large  number  of  facts.  To 
adopt  some  method  in  the  description  of  the  symptoms,  we 
shall  follow  the  example  of  Laennec,  and  divide  phthisis 
into  two  principal  stages  ;  the  one  anterior,  and  the  other 
subsequent  to  the  softening  and  evacuation  of  the  tubercu- 
lous matter  of  the  bronchia. 

215.  First  Stage.  —  In  the  majority  of  instances  the  cause 
of  the  disease  was  unknown.  One  third  of  the  patients 
ascribed  the  first  symptoms  to  alternations  of  heat  and  cold, 
to  which  their  avocations  exposed  them  ;  to  draughts  of  air  ; 
to  immersion  of  the  feet  in  cold  water  ;  to  drinking  cold  water 
when  perspiring  ;  but  the  greater  number  of  those  who  referred 
their  disease  to  draughts  of  air  or  alternations  of  heat  and  cold 
to  which  they  were  exposed  by  their  profession,  were  far  from 
being  confident  or  positive  as  to  the  accuracy  of  their  statements  ; 
it  was  simple  conjecture  on  their  part.  A  very  few  referred, 
with  considerable  precision,  the  first  symptoms  of  having  taken 
cold,  to  twenty-four,  thirty-six,  or  forty-eight  hours  after  the 
apphcation  of  the  cause  to  which  they  attributed  it. 

216.  Whether  an  apparent  cause  did  or  did  not  exist,  the 
affection  generally  commenced  with  a  slight  cough,  at  first  ex- 
citing no  attention,  but  it  was  regarded  as  a  simple  cold,  \\o 
which  many  of  them  were  subject.  The  cough  was  usually 
accompanied  with  clear  expectoration,  like  frothy  saliva,  or 
(as  existed  in  one  tenth  of  the  cases)  it  continued^free  from  all 


Chap.    l.J  FIRST    STAGE.  167 

secretions  during  many  months.  In  some  cases  it  came  on  in 
paroxysms,  and  made  rapid  progress.  After  a  certain  time, 
the  sputa  were  less  clear,  slightly  greenish,  and  a  little  opaque. 
They  completely  changed  their  characters  in  the  second  pe- 
riod. In  some  instances,  the  first  symptoms  were  preceded 
by  a  more  or  less  copious  haemoptysis,  or  this  latter  symptom 
commenced  at  the  same  time  with  the  rest.  The  breathing 
was  not  at  first  sensibly  affected,  and  by  some  patients  dys- 
pnoea was  only  complained  of  at  a  somewhat  advanced  period 
of  the  disease.  Very  frequently  there  were  variably  acute 
pains  between  the  shoulders  and  in  the  sides  of  the  thorax, 
some  time  after  the  commencement.  If,  in  this  stage  of  the 
complaint,  we  ausculted  the  patient,  the  respiratory  murmur 
was  not  sensibly  changed  ;  at  least  this  was  commonly  the  case, 
especially  when  there  were  only  grey  granulations.  In  other 
cases,  the  respiration  was  feeble  under  one  of  the  clavicles  ;  or 
in  the  same  regions,  and  in  a  very  limited  space,  there  was  a 
slight  mucous  and  sonorous  râle,  with  rather  less  clearness  on 
percussion  than  on  the  opposite  side. 

217.  To  these  local  symptoms  were  added  various  derange- 
ments of  different  functions.  Occasionally,  from  the  com- 
mencement, there  were  alternations  of  temperature,  and  night 
perspirations  ;  but  most  frequently  these  came  on  at  a  more 
advanced  period,  and  generally  in  the  second  stage  of  the  dis- 
ease. With  very  few  exceptions,  the  appetite  was  at  first 
unaffected,  but  afterwards  gradually  diminished.  If  the  cough 
was  violent,  it  sometimes  caused  vomiting  after  food  ;  and 
when  this  only  was  the  cause,  the  sickness  was  of  short  dura- 
tion. Very  few  had  diarrhoea.  The  strength  diminished 
more  or  less  rapidly,  and  emaciation  was  soon  associated  with 
the  other  symptoms,  though  at  first  its  progress  was  very 
gradual. 


168  SYMPTOMS.  GENERAL  DESCRIPTION  ;       [Part  II, 

218.  Second  Stage. — The  cough  was  now  usually  more 
frequent  and  more  inconvenient,  especially  during  the  night. 
The  sputa  assumed  a  greenish  color,  were  striated  by  yellow 
opaque  lines,  free  from  air,  and  presented  a  peculiar  appear- 
ance, being  of  a  rounded  shape,  and  as  if  torn  on  the  edges. 
Occasionally,  from  the  influence  of  regimen  and  demulcents, 
some  of  these  characters  disappeared,  but  sooner  or  later 
again  returned.  Towards  the  close  of  life,  they  frequently 
resembled  pea-soup  with  a  greenish  or  greyish  tinge.  Last- 
ly, they  were  often  mingled  with  expectoration,  similar  to 
what  is  observed  in  the  first  stage  ;  haemoptysis  was  pretty 
frequent,  but  in  general  not  copious  ;*  the  dyspnoea  was  in  pro- 
portion to  the  progress  of  the  disease  ;  the  pains  in  the  thorax 
were  often  more  acute  than  previously  ;  sometimes  there  were 
very  urgent  pleuritic  symptoms,  demanding  active  treatment. 
The  patients  usually  lay  with  the  head  low,  and  the  decubitus 
varied  ;  however,  in  some  cases  it  was  exclusively  on  the  side 
opposite  to  the  large  excavations.  By  auscultation,  more  or 
less  evident  pectoriloquy,  gurgling  râle  or  tracheal  respira- 
tion, could  be  detected  in  one  or  various  points,  corresponding 
to  the  summit  of  the  lungs,  and  in  one  third  of  the  cases  per- 
cussion was  dull  under  one  clavicle,  and  quite  frequently 
to  a  considerable  extent.  It  was  also  in  this  stage  of  the 
complaint  that  the  symptoms  peculiar  to  ulcerations  of  the 
epiglottis,  larynx,  and  the  different  lesions  of  the  mucous 
membrane  of  the  stomach,  developed  themselves. 

219.  In  the  greater  number  of  instances,  the  fever  was  con- 
tinuous with  occasional  exacerbations.  These  occurred  in  the 
evening,  with  rigors,  heat,   and   perspiration.     The  thirst  was 

*  "  In  this  state  of  tbt  disease  haemoptysis  to  any  extent  is  very  uncom- 
mon." —  Laennee,  page  348.  —  Cowan. 


Chap.  1.] 


SECOND    STAGE. 


169 


urgent,  except  when  the  progress  of  the  disease  was  very- 
slow.  The  appetite,  which  was  in  general  variable,  diminish- 
ed as  debility  increased,  or  even  in  some  examples  the  ano- 
rexia was  complete,  though  the  mucous  membrane  of  the 
stomach  was  healthy,  or  only  presented  traces  of  recent  and 
unimportant  lesions.  In  a  small  number  of  cases  the  alvine 
evacuations  continued  regular  until  the  last.  Many  experi- 
enced diarrhœa  twenty  or  thirty  days  only  before  death  ;  but 
in  the  majority  it  commenced  very  much  earlier.  The  ema- 
ciation made  rapid  progress,  and  unless  some  unexpected  acci- 
dent intervened,  as,  for  example,  perforation  of  the  substance 
of  the  lungs,  death  took  place  in  the  last  stage  of  marasmus, 
without  any  disturbance  of  the  intellectual  faculties. 

220.  The  duration  of  each  stage  was  very  variable,  and 
proportionate  to  that  of  the  disease  itself,  the  limits  of  which 
are  shown  in  the  follov/ins  table  :  — 


Duration  of 

Number  of 

Duration  of                                     Nu 

mber  of 

Disease. 

Deaths. 

Disease.                                          Deaths. 

24  Days, 

. 

1 

11  Months, 

2 

35  Days,  . 

. 

2 

12  Months,     , 

5 

50  Days, 

1 

12  Months  and  a  half, 

2 

52  Days,    . 

. 

1 

13  Months  and  a  half. 

1 

81  Days, 

1 

14  Months, 

3 

3  Months, 

,             ^ 

2 

14  Months  and  a  half. 

1 

3  Months  and 

a  half, 

3 

15  Months, 

5 

4  Months,     . 

2 

17  Months,     . 

2 

4  Months  and 

a  half, 

2 

18  Months, 

1 

5  Months,     . 

9 

19  Months,     . 

1 

5  Months  and 

a  half, 

2 

20  Months, 

1 

6  Months,     . 

7 

2  Years, 

8 

6  Months  and 

a  half. 

1 

2  Years  and  a  half, 

2 

7  Months,     . 

8 

3  Years, 

4 

7  Months  and 

a  half, 

5 

4  Years, 

6 

8  Months,     . 

4 

5  Years, 

2 

9  Months, 

, 

7 

10  Years, 

1 

9  Months  and 

a  half. 

1 

12  Years, 

2 

10  Months, 

, 

3 

14  Years, 

1 

10  Months  and 

a  half. 

1 

20  Years, 

1 

Total, 


63 


Total, 


51 


170  SYMPTOMS. GENERAL    DESCRIPTION  ;        [Part  D, 

That  is  to  say,  out  of  one  biindred  and  fourteen  cases,  the 
duration  of  which  has  been  determined  as  accurately  as  pos- 
sible, rather  more  than  two  tenths  have  died  from  the  first 
to  the  sixth  month  of  the  disease  ;  four  tenths  from  the 
sixth  to  the  twelfth  month  ;  rather  less  than  a  fourth  from  the 
first  to  the  second  year  ;  and  less  than  one  fifth  from  the 
second  to  the  twentieth. 

221.  We  have  endeavored  to  discover  whether  age  had 
any  influence  on  the  more  or  less  rapid  progress  of  the  affec- 
tion ;  and  we  have  never  found  this  to  be  the  case,  unless, 
perhaps,  in  some  instances  of  very  acute  phthisis. 

222.  On  the  other  hand,  the  influence  of  sex  appears  cer- 
tain ;  for  if  the  proportion  of  deaths  in  male  and  female  phthis- 
ical patients  in  whom  the  disease  had  lasted  more  than  a  year, 
was  equal,  it  was  as  thirty  to  forty-two,  when  death  occurred 
during  the  course  of  the  first  year. 

Perhaps  this  difference  niay  be  explained  by  considering  that 
the  adipous  state  of  the  liver,  and  the  softening  with  diminished 
consistence  of  the  gastric  mucous  membrane  were  much  more 
frequent  in  women  than  in  men  (89, 161),  and  that  these  lesions 
must  necessarily  have  accelerated  the  fatal  catastrophe. 

223.  As  to  the  mortality  from  phthisis  compared  with  other 
diseases,  it  was  nearly  as  one  to  two  ;  for  out  of  three  ])un- 
dred  and  fifty-eight  fatal  cases  in  the  v^ards  of  M.  Chomel, 
during  three  years  and  a  half,  one  hundred  and  twenty-three 
were  phthisical  ;  the  remaining  two  hundred  and  thirty-five 
included  a  variety  of  other  diseases.  And  if  to  this  number 
of  phthisical  subjects,  we  add  those  who,  dying  of  some  other 
disease,  had  tubercles  or  tuberculous  cavities  in  the  lungs  (viz. 
40),  we  find  that  out  of  three  hundred  and  fifty-eight  cases,  one 
hundred  and  sixty-three,  or  nearly  half,  presented  pulmonary 
tubercles  in  the  lungs,   and  were  really  consumptive  !    This 


Chap.    1.]    MORTALITY    OP    PHTHISIS;    COUGH;    SPUTA.        171 

proportion  is  immense  ;  it  does  not,  however,  include  a  com- 
parison with  all  those  cases  which  are  necessarily  fatal,  in  the 
actual  state  of  our  knowledge.  Let  us  now  successively 
study  the  symptoms  we  have  enumerated. 

224.  Cough.  —  It  varied  much.  Some  patients  only 
coughed  towards  the  close  of  life  (Obs.  31,  32),  although 
cavities  had  existed  for  some  time.  Others,  and  they  were 
not  numerous,  coughed  very  little,  or  even  after  a  certain 
time,  not  at  all,  until  the  disease  approached  its  termination, 
although  there  seemed  to  be  a  tuberculous  affection  from  the 
beginning  (Obs.  30).  The  greater  part  complained  of  a 
troublesome  cough,  especially  at  night,  forcing  them  to  resort 
to  opium  to  obtain  sleep,  which  did  not  always  succeed. 
This  cough  sometimes  came  on  in  paroxysms,  caused  a  good 
deal  of  dyspnœa,  frequently  vomiting,  and  an  oppressive  sen- 
sation in  the  epigastrium.  In  general  the  violence  and  fre- 
quency of  the  cough  were  in  proportion  to  the  more  or  less 
rapid  progress  of  the  disease. 

225.  Expectoration.  —  The  passage  from  the  first  stage  to 
the  second  was,  as  we  have  already  observed,  indicated  by  a 
remarkable  change  in  the  aspect  and  form  of  the  sputa. 
From  being  white,  mucous  and  spumous,  they  became  green- 
ish, opaque,  deprived  of  air,  and  streaked  with  more  or  less 
numerous,  dull,  yellow  lines,  which  made  them  sometimes 
seem  composed  of  many  colors.  Auscultation  of  the  summit 
of  the  lungs  detected  resonance  of  the  voice,  pectoriloquy,  or 
a  very  strong  respiratory  murmur,  as  if  tracheal,  often  mingled 
with  a  gurgling,  or  sometimes  with  a  dry  râle.  We  occasion- 
ally found  among  the  sputa  fragments  of  a  white,  opaque 
substance,  resembling  (as  Bayle  has  remarked)  boiled  rice  ; 
but  this  was  rare,  and  in  the  majority  of  instances  the  striated 
sputa  were  alone  present. 


172  SYMPTOMS.  —  SPUTA,  [Part  II, 

After  some  time  the  striated  appearance  and  the  occasional 
fragments  of  white  substance  ceased  to  be  observed.  The  ex- 
pectoration became  uniform  in  composition,  and  separated  into 
rounded,  distinct  masses,  with  their  edges  as  if  torn  and  floc- 
culent.  These  masses  were  heavy  and  more  or  less  consistent  ; 
they  did  not  sink  always,  but  floated  sometimes  on  the  surface 
of  a  clear  liquid,  which  was  expectorated  with  them.  After 
presenting  some  time  a  greenish-yellow  tinge,  they  assumed  a 
greyish,  dirty  appearance,  very  analogous  to  what  we  find  in 
old  tuberculous  excavations  ;  this  took  place  towards  the  close 
of  life,  from  fifteen  to  twenty,  or,  most  frequently,  only  a  few 
days  preceding  death.  They  then  diminished  in  consistence, 
spreading  out  on  the  sides  of  the  spitting  box,  resembling  the 
pulp  of  boiled  peas,  and  were  occasionally  streaked  with  blood 
or  surrounded  by  a  pink  areola.  This  latter  color  would  no 
doubt  have  been  observed  more  frequently,  if  the  patients  had 
continued  to  expectorate  during  the  last  twenty-four  hours, 
for  we  generally  found,  after  death,  the  bronchial  mucosities 
more  or  less  tinged  with  blood. 

226.  The  union  of  all  these  characters  is  sufficient,  without 
other  examination,  almost  certainly  to  indicate  tuberculous 
excavation  in  the  lungs.  We  lay  stress  upon  all,  for  green, 
opaque,  homogeneous  sputa  exist  in  chronic  and  sometimes 
also  in  acute  catarrh  ;  but  they  are  not  then  striated,  and  do 
not  contain  those  white  particles  we  have  described,  and  are 
not  usually  in  distinct  masses  as  in  phthisis.  The  rounded,  num- 
mulated  form  (pelotonnée)  of  the  sputa  is  certainly  one  of  their 
most  valuable  peculiarities  with  regard  to  diagnosis,  and  in  two 
very  remarkable  examples  (Obs.  30,  33),  both  to  M.  Chomel 
and  ourselves,  it  was  the  first  indication  of  a  tubercular  affection. 

It  is,  however,  right  to  mention,  that  a  few  days  before 
death,  we  have  in  two  instances  seen  the  sputa  thus  nutn- 


Chap.   1.]  IMPORTANT    FOB    THE    DIAGNOSIS.  173 

mulated  and  opaque,  although  no  tubercles,  tuberculous  exca- 
vations, or  dilated  bronchia  existed  in  the  lungs. 

227.  The  expectoration  we  have  described,  with  the  ex- 
ception of  three  cases,  was  constantly  present.  In  these  in- 
stances it  always  continued  mucous,  spumous,  whitish  or  slightly 
yellow,  or  even  greyish,  semi-transparent,  as  if  vitrified,  without 
ever  presenting  that  separation  into  distinct  masses,  which  we 
have  shown  to  be  so  important. 

In  the  majority  of  instances,  the  greenish,  opaque,  striated 
sputa,  were  associated  with  a  mucous,  spumous  and  more  or 
less  viscous  expectoration,  retaining  the  characters  observed  in 
the  first  stage  ;  or,  instead  of  this,  they  floated  in  a  clear,  thin 
fluid,  like  saliva.     Sometimes  they  were  dry,  as  it  were. 

228.  The  quantity  of  the  expectorated  matter  varied  at 
diflerent  periods  of  the  affection.  In  the  commencement,  if 
the  progress  was  rapid,  it  was  sometimes  very  abundant,  from 
ten  to  twenty  ounces  in  the  four  and  twenty  hours.  In  the 
second  stage  it  was  less  copious,  unless  indeed  the  expectora- 
tion of  the  first  period  was  prolonged  in  conjunction  with  that 
of  the  second.  When  this  was  not  the  case,  it  very  frequent- 
ly happened,  that  the  bottom  of  the  spitting  vessel  was  scarcely- 
covered,  and  we  have  never  seen  it  completely  filled.  A 
smallnumberof  patients  only  expectorated  a  few  isolated  sputa 
in  the  twenty-four  hours.  In  two  instances,  during  some 
days,  all  expectoration  ceased.  A  third  (a  fatal  case  of  croup 
in  a  woman,*  who  had  large   tubercular   excavations  in   the 

*  Vide  sixth  observation  in  Mémoire  sur  le  Croup,  considéré  chez. 
V Adulte;  Recherches  sur  diverses  Maladies,  page  203.  —  Louis. — This 
memoir  contains  nine  examples  of  this  affection,  nearly  all  occurring  during 
the  course  of  other  diseases  ;  two  in  phthisis  ;  three  in  t3'phu3  ;  one  in 
chronic  pleurisy  ;  one  in  gastro-enteritis  ;  two  in  gastritis.  The  progress 
of  the  disease  was  not  affected  by  the  complications.    The  symptoms  were 


174  SYMPTOMS.  —  sputa;  [Part  II, 

iungs,  and  ^vhose  illness  dated  nine  months  at  the  time  we 
observed  her),  never  expectorated  at  any  period  of  the  dis- 
ease ;  and  the  care  we  took  to  ascertain  the  correctness  of 
this  fact  assures  us  of  its  truth. 

After  continuing  for  some  time  greenish  and  opaque,  &ic., 
from  the  influence  of  repose,  regimen  and  demulcents,  they 
were  more  or  less  modified  ;  they  were  less  opaque,  occa- 
sionally vitrified  in  appearance,  retaining  or  losing  their 
rounded  form,  and  after  some  time  resuming  their  former 
aspect. 

229.  During  the  first  stage,  when  the  expectoration  is  mu- 
cous and  spumous,  the  gurgling  and  pectoriloquy  are  absent, 
and,  consequently,  there  is  no  excavation;  the  sputa,  therefore, 
could  only  come  from  the  bronchia.  At  a  more  advanced 
period,  they  were  at  once  the  product  of  bronchial  secretion, 
and  of  the  contents  of  the  tuberculous  excavations.  Of  this 
we  have  proofs  in  the  change  in  their  physical  characters 
from  the  moment  that  pectoriloquy  and  gurgling  announced 
the  softening  of  tubercles,  and  their  communication  with  the 
air  tubes  ;  and  more  especially  in  the  resemblance  of  the  yel- 
lowish streaks  we  have  described,  with  the  liquefied,  tubercu- 
lous matter,  such  as  we  find  it  in  recent  excavations.  Still  later 
in  the  disease  the  same  double  origin  is  evident,  if  we  recollect 
that  we  frequently  find  in  the  bronchia  communicating  with  the 


sore  throat,  heat,  redness  of  the  pharynx,  &c.  with  dysphagia.  Then  pain 
in  larynx  and  trachea,  gradually  increased  alteration  of  the  voice,  with  dys- 
pnœa,  anxiety,  but  very  rarely  with  paroxysms  of  suffocation.  The  forma- 
tion of  the  false  membrane  was  always  from  above  downwards,  sometimes 
commencing  in  the  nasal  fossae.  The  duration  varied  from  six  to  eight  days; 
only  one  recovered.  The  absence  of  suffocating  paroxysms  and  the  forma- 
tion of  the  false  membrane  from  above  downwards,  seem  principally  to  dis- 
tinguish it  from  the  same  affection  in  children.  —  Cowajv. 


Chap.   1.]    MODIFIED  BY  THE   STATE   OF  THE  BRONCHIA.     175 

excavations,  a  substance  precisely  analogous  to  the  contents  of 
the  latter  ;  that  towards  the  close  of  life  this  substance  is  not 
sensibly  different  from  the  expectoration  ;  that  the  differences 
so  frequently  observed  in  the  results  of  auscultation  before  and 
after  expectoration  suppose  some  change  of  proportion  in  the 
fluids  contained  in  cavities  ;  and,  moreover,  that  it  is  impossible 
for  bronchia  to  communicate  freely  with  excavations,  and  not 
receive  by  the  impulses  of  the  cough,  a  certain  portion  of  their 
contents  ;  and,  lastly,  that  the  situation  of  many  of  these  open- 
ings at  the  inferior  part  of  the  excavation  shows  that  simple 
gravitation  is  often  sufficient  to  produce  the  same  effect. 

These  reflections  are  strengthened  by  the  pathological  state 
of  the  bronchia  in  a  great  number  of  cases.  We  have,  in  fact, 
seen  (36),  that  when  they  were  intensely  red  and  much  thick- 
ened, it  was  not  in  the  neighborhood  of  masses  of  grey  or 
tuberculous  matter,  but  in  that  of  the  large  excavations  ;  a 
fact  which  cannot  be  easily  explained,  unless  we  admit  the 
passage  of  the  contents  of  these  excavations  into  the  bronchia. 

230.  From  the  above  statements,  we  think  it  more  than 
probable,  that  the  violent  inflammation  of  the  bronchial  mu- 
cous membrane,  at  this  stage  of  the  disease,  considerably 
modifies  the  expectoration  ;  that  at  a  certain  period,  the 
opaque,  greenish  and  greyish  sputa  are  equally  the  product  of 
bronchial  secretion  as  of  the  cavernous  parietes  ;  and  that 
little  or  no  difference  exists  between  the  matter  furnished  by 
the  one  or  the  other.* 

*  It  would  be  easy  to  multiply  opinions  and  experiments  relative  to  the 
expectoration  in  phthisis  ;  we  think,  however,  that  Aretasus  is  right  in 
regarding  them  rather  as  objects  of  historical  research  than  applicable  to 
practical  utility.!  —  Cowan. 

1 1  cannot  agree  with  the  translator,  for  it  appears  to  me  that  it  is  neces- 
sary to  study  the  peculiarities  of  the  expectoration  as  much  as  those  of  any 
other  secretion,  or  the  state  of  any  function  in  the  body.     Aretaeus  knew 


176  SYMPTOMS.  —  Hemoptysis;  [Part  II, 

231.  Hcemoytysis. — It  was  present  in  two  thirds  of  the 
cases,  fifty-seven  times  out  of  eigljty-seven. 

By  copious  hcemoptysis,  we  understand  the  expectoration 
(in  a  few  minutes,  a  quarter  of  an  hour,  half  an  hour,  or  an 
hour),  of  several  ounces  of  more  or  less  liquid,  spumous  blood, 
occasionally  dark  colored  and  coagulated,  and  sometimes  ac- 
companied with  contractions  of  the  diaphragm,  which  induce 
patients  to  suppose  they  have  vomited  the  blood.  Haemop- 
tysis is  inconsiderable  when  a  few  mouthfuls  of  frothy  blood 
are  rendered  either  pure  or  mingled  with  the  expectoration. 
This  may  be  repeated  for  several  months  successively. 
Both  kinds  seemed  equally  frequent.  Out  of  fifty-seven 
patients,  the  haemoptysis  was  copious  in  twenty-five. 

232.  Copious  or  otherwise,  it  sometimes  preceded  both  the 
cough  and  expectoration.  This  was  the  case  with  twelve  of 
our  patients,  and  in  eight  out  of  these  the  hcernorrhage  was 
copious.  The  quantity  was  more  frequently  abundant  (in  the 
proportion  of  nine  to  seven),  in  the  course  of,  or  at  the  com- 
mencement of  the  first  stage  of  the  complaint.  Bloody  ex- 
pectoration was  rare  towards  the  termination,  when  the  patient 
was  very  weak.  We  have  only  observed  it  at  this  period  in 
four  cases,  twice  copious,  and  twice  in  small  quantity. 

233.  Are  we,  however,  to  consider  the  haemoptysis,  espe- 
cially when  copious,  which  precedes  cough  and  expectoration, 
as  the  precursor  of  tubercles,  or  simply  as  a  symptom  which 
reveals  their  presence  ?  For  nearly  three  years  we  have  con- 
stantly questioned  every  patient  under  our  care,  and  who  was 
attacked  with  any  other  disease  than  phthisis,  if  they  had  ever 

nothing  of  various  means  which  we  now  possess  of  verifying  our  results  ;  he, 
therefore,  ought  not  to  he  quoted  upon  this  question.  But  an  unanswerable 
argument  upon  the  necessity  of  minute  attention  to  sputa  will  be  found  in 
the  last  four  lines  of  paragraph  226.  —  H.  I.  B. 


Chap.   1.]    IS    IT    A    SYMPTOM    OR    CAUSE    OF    PHTHISIS?     177 

spit  blood,  and  we  have  invariably  received  answers  in  the  nega- 
tive, except  when  external  violence  had  been  received  on  the 
chest,  or  when  the  catamenia  had  been  suddenly  suppressed. 
Patients  subject  to  bronchitis  during  many  years,  and  whose 
breathing  was  usually  free,  had  never  had  haemoptysis.  On 
the  other  hand,  we  have  seen  some  individuals  with  tubercles 
in  the  lungs,  who  had  never  experienced  any  direct  symptom 
announcing  their  presence  ;  so  that  nothing  seems  to  be  less 
surprising  than  that  pulmonary  tubercles  should  give  rise,  at  a 
certain  period  of  their  existence,  to  a  single  symptom,  and  in 
particular  to  expectoration  of  blood  ;  we  therefore  think  that 
haemoptysis  (with  the  exceptions  already  mentioned),  when- 
ever it  occurs,  renders  the  presence  of  tubercles  in  the  lungs 
infinitely  probable.  We  limit  our  conclusion  to  probability, 
for  many  well-attested  facts  appear  fortunate  exceptions.* 

Analogy,  moreover,  is  in  favor  of  what  we  advance.  For, 
when  haemorrhage  occurs  in  any  internal  organ,  it  is  almost 
constantly  a  symptom  of  more  or  less  considerable  alteration 
of  structure.  Let  us  add  also,  that  when  haemoptysis  pre- 
ceded the  other  symptoms  of  tubercles,  it  was  occasionally 
followed  by  dyspnoea  ;  it  came  on  suddenly  (Obs.  32,  &;c.), 
usually  when  the  patient  appeared  in  perfect  health,  without 

*  Pulmonary  apoplexy  has  been  considered  both  by  Laennec  and  others,  as 
a  frequent  cause  of  hcemoptysis.  M.  Louis,  from  the  consideration  of  facts, 
thinks  the  coincidence  rare  ;  he  has  very  frequently  found  this  lesion  when 
no  haemoptysis  had  taken  place. 

Hypertrophy  of  the  left  ventricle  would  naturally  be  thought  peculiarly 
predisposing  to  hœmoptysis,  yet  out  of  twenty-seven  cases  of  this  description 
in  not  one  was  it  experienced,  while  in  six  of  them  the  pulmonary  artery  and 
its  ramifications  were  evidently  enlarged.  (Vide  £a:a?nen.  page  38).  There 
is  often  a  wide  difference  between  facts  and  our  explanation  of  facts.  — 
Cowan. 


178  SYMPTOMS.  —  HiEMOPTYSis  ;  [Part  II, 

previous  phenomena,  or  any  apparent  cause  ;  and  it  is  not  un- 
natural to  suppose  that  the  then  concealed  cause  was  identical 
with  what  subsequently  reproduced  the  symptom.  But  we 
shall  confine  ourselves  to  these  iew  reflections,  which  are 
indulged  in  rather  to  excite  examination,  than  to  supply 
facts. 

234.  Sex  had  an  evident  influence  on  the  occurrence  of 
haemoptysis.  It  was  more  frequent  in  women  than  in  men,  in 
the  proportion  of  three  to  two.  Thus,  out  of  forty-two  women 
who  were  carefully  questioned  on  this  point  thirty-six  had 
expectorated  blood  ;  but  out  of  thirty-eight  men,  it  was  so 
with  only  twenty-one. 

235.  The  proportion  of  haemoptysis  in  different  ages  was 
not  the  same  in  both  sexes.  One  third  of  the  female  patients, 
between  the  ages  of  nineteen  and  forty,  had  not  experienced 
it  ;  while,  from  forty  to  sixty-five,  it  was  only  absent  in  one 
seventh  ;  an  inverse  proportion  to  what  ought  to  have  existed, 
if,  according  to  the  opinion  of  some  physicians,  haemoptysis 
may  be  considered  in  some  cases  as  a  supplement  to  dimin- 
ished or  suppressed  catamenial  discharge.*  In  men,  on  the 
contrary,  the  proportion  was  exactly  similar,  either  before  or 
after  the  age  of  forty  ;  so  that  out  of  twelve  cases  above  this 
period,  six  had  expectorated  blood  ;  and  out  of  twenty-six 
below  forty,  fourteen.  Should  the  small  number  of  the  facts 
we  have  analyzed  be  deemed  insufficient  to  establish  satisfac- 
torily a  relation  between  the  age  and  the  frequency  of  haemop- 

*  It  would  appear  to  us  that  the  age  from  forty  to  sixty-five  was  most 
liable  to  menstrual  disturbance  ;  which,  if  not  usually  so  violent  as  at  an 
earlier  age,  is  at  least  more  general.  Perhaps  this  view  of  the  subject  is 
supported  by  what  the  author  says  farther  on,  that  the  majority  of  the  cases 
of  hajmoptysis  were  among  robust  constitutions.  —  Cowan. 


Chap.   1.]       EFFECT    OP    SEX    AND    AGE    UPON    IT.  179 

tysis  in  either  sex,  it  will  at  least  serve  to  fix  the  attention  of 
observers,  and  stimulate  them  to  farther  investigations. 

236.  The  age  seemed  without  evident  influence  on  the 
quantity  of  blood  expectorated  ;  and  the  frequency  of  its 
recurrence  seemed  to  depend  on  the  duration  of  the  disease. 

237.  We  have  also  endeavored  to  decide  whether  there  ex- 
isted any  connexion  between  haemoptysis,  and  the  strength  or 
weakness  of  the  general  constitution.  Out  of  forty-eight 
cases,  haemoptysis  occurred  in  an  equal  number  of  feeble 
and  strong  constitutions,  though  among  the  women  there  was 
a  predominance  of  robust  constitutions. 

238.  In  some  instances,  copious  haemoptysis  only  occurred 
once  ;  it  was  seldom  repeated  three,  four,  or  a  greater  num- 
ber of  times.  The  following  observation,  while  an  example 
of  this  description,  will  also  furnish  an  instance  of  the  very  rare 
fact  of  the  symptoms  of  typhus  fever  coming  on  during  the  last 
stage  of  marasmus,  and  after  very  copious  evacuations  of 
blood. 


TENTH     OBSERVx\TION. 

A  YOUNG  man,  aet.  18,  well  made,  tall,  with  black  hair, 
impetuous  temper  and  moderate  corpulency  was  admitted 
into  the  hospital  of  La  Charité,  November  26th,  1821.  Born 
of  healthy  parents,  and  subject  to  dyspnœa  from  his  infancy, 
he  was  seized  in  the  end  of  October,  while  in  perfect 
health,  and  without  any  appreciable  cause,  with  a  copious 
haemoptysis.  The  expectoration  of  blood  had  since  con- 
tinued, though  in  diminished  quantity,  until  the  last  few  days. 
Cough  had  commenced  with  the  haemoptysis,  was  accompa- 


180  SYMPTOMS. HaiMOPTYSIS  î  [Paît  II, 

nied  with  some  expectoration,  and  caused  little  inconvenience. 
No  pain  in  chest,  heat  nor  rigors.  Some  sensibility  to  a  low 
temperature.  The  patient  had  refused  every  kind  of  treat- 
ment, continued  his  usual  food  and  occupations,  and  decided 
very  reluctantly  to  enter  the  hospital. 

27th.  Expression,  rather  lively  ;  general  strength,  only 
slightly  diminished  ;  breathing,  little  accelerated  ;  cough,  rare, 
and  excited  by  lying  on  his  back  ;  expectoration,  viscous, 
yellowish  and  spumous  ;  some  of  the  sputa  of  a  bright  red. 
Cannot  lie  easily  on  left  side  ;  percussion,  rather  duller  under 
left  clavicle  than  under  the  right.  Respiratory  murmur,  oc- 
casionally absent  in  som.e  parts,  and  on  the  lateral  parts  of  the 
left  side  we  heard  with  the  stethoscope  a  sound  very  similar 
to  that  caused  by  a  bubble  of  air  when  agitated  with  water  in 
a  moderately  sized  tube.  Pulse,  calm,  rather  full  ;  tempera- 
ture, natural  ;  tongue,  clean  ;  appetite,  good  ;  no  thirst  ;  ab- 
domen, yielding,  not  painful.  Slight  diarrhœa  the  last  two 
days. 

(V.  S.  §  viiij.  ;  barley  water  with  gum  syrup  ;  gum  po- 
tion ;  a  pint  of  milk  ;  one  fourth  of  bread  allowance.) 

No  evident  change  the  next  day.  29th.  Very  soon  after 
the  visit,  he  was  attacked  with  a  copious  haemoptysis,  esti- 
mated at  §  vj.  Blood,  dark-colored  or  frothy,  and  bright 
red.  Respiration,  as  before.  Auscultatory  phenomena,  as 
before. 

(V.  S.  g  viij.  ;  blister  to  the  left  arm  ;  barley  water  ;  muci- 
laginous mixture  and  soups). 

30th.  Fresh  haemoptysis,  accompanied  with  sense  of  drag- 
ging at  epigastrium  ;  no  increase  of  cough  ;  no  sense  of  heat 
in  chest,  and  no  previous  rigors. 

Up  to  the  8th  of  December,  he  merely  expectorated  a  few 
sputa  tinged  with  blood  ;  but  on  the  morning  of  the  same  day, 


Chap.  1.]  FREQUENCY.  181 

while  perfectly  quiet,  was  seized  with  an  haemoptysis  more 
copious  than  the  first  ;  respiration,  weaker  posteriorly  on  the 
left  side  than  on  the  right. 

(V.  S.  ad   Sxij). 

The  next  day,  slight  soreness  of  throat,  with  difficult  deglu- 
tition ;  thirst,  not  urgent  ;  bowels,  regular  ;  heat  of  surface, 
every  where  natural  ;  pulse,  accelerated  ;  sputa,  white  ;  face, 
emaciated,  and  of  a  dull  white  aspect. 

From  the  9th  to  the  15th,  three  copious  hsemoptyses  took 
place,  which  were  treated  by  two  bleedings  and  a  large  blister 
between  the  shoulders.  On  the  16th,  sputa  moderately 
thick,  yellowish,  and  imperfectly  divided  into  distinct  portions 
(pelotonnés).  During  the  following  fifteen  days,  they  pre- 
sented nearly  the  same  appearance  ;  breathing  was  more 
oppressed  ;  the  cough  increased  in  violence  ;  heat  of  surface, 
slightly  elevated  ;  night  perspirations  ;  the  appetite  improved  ; 
the  food  was  gradually  augmented  ;  and  on  28th,  the  patient 
took  daily  a  quart  of  milk  with  four  ounces  of  bread,  and  some- 
times rather  more. 

Jan.  2d.  Considerable  dyspnœa;  cough,  much  more  when 
lying  on  the  left  side  than  on  right  ;  no  râle  could  be  heard  an- 
teriorly on  auscultation  ;  pulse,  jerking  and  pretty  frequent  ; 
the  lively  expression  had  given  way  to  that  of  weariness  ; 
he  had  scarcely  left  his  bed  for^some  days  ;  considerable  ema- 
ciation. 

(Two  rice  creams). 

From  the  2d  to  the  8th.  No  appreciable  change,  unless  in 
the  respiratory  murmur,  which  became  very  coarse  under  the 
left  clavicle.  9th.  The  tongue,  which  had  been  natural,  then 
assumed  a  bright  red  color.  10th.  Almost  complete  deafness. 
11th.  This  symptom  increased  ;  the  patient  was  continually 
groaning  ;  pulse,  rather  full  and  tumultuous. 


182  SYMPTOMS.  —  HEMOPTYSIS  ;  [Part  II, 

^V.  S.   §  viij,  ;  barley  emulsion  for  drink). 

12th.  Tongue,  dry  and  blackish;  thirst,  intense;  heat  of 
skin,  rather  pungent  ;  pulse,  less  full  and  less  tumultuous  than 
yesterday  ;  gurgling  under  left  clavicle  and  sibilant  râle  under 
the  right. 

(V.  S.   I  viij). 

The  blood  was  covered  with  a  pretty  thick  buff.  The  day 
after,  three  stools  were  passed. 

In  the  night  of  13th  to  14th,  almost  constant  delirium.  On 
the  morning  of  the  14th,  face,  pale,  air  of  prostration  ;  deaf- 
ness continues;  heat  of  skin,  dry  and  pungent;  breathing, 
noisy  with  crepitating  râle  on  the  left  side  ;  cough,  frequent  ; 
sputa,  scanty  ;  tongue,  dry  and  encrusted. 

(Infusion  of  violets  ;  gum  potion). 

15th.  At  visit,  a  little  less  dulness  of  eye  ;  pulse,  as  be- 
fore, rather  full  ;  in  other  respects  as  yesterday.  The  follow- 
ing night  he  was  delirious.  On  the  morning  of  the  16th,  face, 
unequally  flushed  ;  intelligence,  good  ;  tongue,  dry  ;  temper- 
ature, elevated  ;  cough,  rather  less  frequent  ;  gurgling  was 
heard  under  left  clavicle  ;  the  patient  frequently  uncovered 
his  chest. 

The  same  symptoms  persisted  until  death,  which  took  place 
on  the  18th,  at  two,  p.  m. 

Opening  of  the  corpse  forty-two  hours  after  death. 

Exterior.  —  Emaciation,  almost  extreme. 

Head.  —  Brain,  firm,  not  injected  ;  two  small  spoonfuls  of 
serum  in  the  lateral  ventricles  and  in  the  inferior  occipital 
fossae. 

(The  larynx  was  not  examined). 

Chest.  —  Some  adhesions  at  the  summit  of  the  lungs. 
The  right  lung  crepitated  and  some  of  the  upper  portions  of 


Chap.  1.]  TREQUENCT.  183 

it  were  slightly  congested,  and  presented  throughout  their 
whole  extent,  numerous  grey,  semi-transparent  granulations, 
of  the  size  of  hemp  seeds.  In  the  left  lung,  the  upper  lobe 
was  completely  converted  into  tuberculous  excavations,  con- 
taining a  muddy,  greyish,  faetid  substance.  These  were  sep- 
arated from  each  other  by  intersections  of  a  grey,  semi-trans- 
parent matter  of  half  a  line  or  more  in  thickness.  The  lower 
lobe  was  similarly  but  much  less  extensively  affected.  The 
septa  dividing  the  excavations  were  thicker,  and  the  pulmonary 
structure  here  and  there  still  permeable  to  the  air.  Heart,  of 
natural  volume  ;  parietes  of  left  ventricle  thinner  than  usual  ; 
aorta,  healthy. 

Abdomen.  —  The  gastric  mucous  membrane  was  pale 
throughout  and  covered  by  thick  mucus  ;  that  of  the  small 
intestine  was  healthy,  with  the  exception  of  some  red,  oval 
spots  in  the  neighborhood  of  the  csecum.  Faeces  were  firm  ; 
spleen,  larger  and  more  consistent  than  natural  ;  the  liver  and 
other  viscera  of  the  abdomen,  healthy. 

239.  This  observation  is  very  remarkable  in  many  respects, 
particularly  as  regards  the  haemoptysis.  The  alarming  repetition 
of  this  haemorrhage  might  by  some  be  attributed  to  the  rapid 
progress  of  the  disease  ;  but  this  influence  cannot  be  admitted, 
since  its  progress  has  been  much  more  rapid  in  other  cases 
(Obs.  33,)  where  no  haemoptysis  was  observed  ;  and  also  be- 
cause, in  every  example  we  have  analyzed,  the  recurrence  of 
the  haemorrhage  was  in  direct  proportion  to  the  duration  of  the 
affection.  Venesection  was  here  carried  as  far  as  the  strength 
of  the  patient  would  permit,  but  without  the  slightest  success. 
The  haemoptysis  frequently  appeared  the  day  after  venesection, 
as  if  the  patient,  instead  of  being  bled,  had  been  guilty  of  some 
excess. 


184  SYMPTOMS.  —  HEMOPTYSIS.  [Part  II, 

240.  As  to  the  question  of  causes,  it  is  proper  to  remark, 
that  the  haemorrhage  came  on  suddenly,  without  any  evident 
reason,  without  previous  symptoms  or  cough,  and  in  the  midst 
of  apparent  heaUh  ;  it  could  not  therefore  be  considered  the  ef- 
fect of  bronchitis,  which  did  not  exist,  but  must  necessarily  be 
attributed  to  the  existence  of  tubercles,  of  which  it  was  the  first 
indication.  If  this  be  admitted,  it  follows  that  the  tubercles 
were  independent  of  all  bronchial  inflammation,  and  were  here 
the  cause  and  not  the  effect  of  bronchitis.  We  shall  again 
insist  upon  this  very  important  consideration,  remarking  only 
that,  in  the  instance  we  are  now  analyzing,  the  opinion  we 
have  expressed  is  confirmed  by  the  results  both  of  ausculta- 
tion and  percussion.  We  have,  in  fact,  seen  that  when  the 
patient  first  entered  the  hospital  percussion  was  less  clear 
under  the  left  clavicle  than  under  the  opposite  one  ;  and  this 
indicated  an  alteration  already  too  considerable  to  be  ascribed 
to  the  inflammation  of  the  bronchial  mucous  membrane, 
which,  whatever  opinion  we  may  adopt,  was  necessarily 
recent. 

241.  We  shall  not  insist  on  the  fact  of  typhus  fever  coming 
on  towards  the  close  of  the  patient's  life  and  after  very  copious 
venesection,  particularly  since  cases  of  this  description  are  so 
rare,  that  we  have  not  met  a  second  example,  and  as  our  ob- 
servation in  this  respect  is  not  sufficiently  exact  to  draw  any 
legitimate  conclusions.  The  mucous  membranes  were  not 
properly  examined  ;  we  have  mentioned  the  universal  pale- 
ness of  that  lining  the  stomach,  but  we  have  said  nothing  as 
to  its  consistence  or  thickness  ;  and  although  it  is  rare  to  find 
it  softened  or  in  any  way  affected  when  its  paleness  is  gen- 
eral, yet  the  fact  is  not  impossible,  and  the  contrary  has  not 
been  stated.  The  red  patches,  mentioned  in  the  small  in- 
testine, were,  perhaps,  the  same  as  those  which  thicken  and 


Chap.   1.]       CAN    TYPHUS    OCCUR    IN    PHTHISIS  ?  185 

ulcerate  in  the  progress  of  typhus  fever,  but  this  cannot  be 
determined  from  so  brief  a  description.  We  cannot,  there- 
fore, afhrm  that  the  symptoms  depended,  or  did  not  depend  on 
one  lesion  or  another,  nor  can  we  expect  for  an  observation  so 
incomplete  that  confidence  which  it  does  not  merit.  It  can- 
not be  too  often  repeated,  that  the,  science  of  medicine  is 
faulty  in  its  foundation  ;  facts,  that  is,  facts  properly  and 
completely  observed,  are  deficient  in  the  great  majority  oj 
instances. 

242.  In  some  rare  examples  haemoptysis  seems  to  have 
been  produced  by  a  paroxysm  of  coughing.  It  almost  always 
occurred  without  any  assignable  cause,  and  was  seldom  ac- 
companied either  with  a  sense  of  heat  or  pains  in  the  chest, 
or  with  any  more  febrile  excitement  than  during  the  days 
which  had  preceded. 

243.  Dyspnoea.  —  It  was  generally  very  slight,  not  com- 
plained of  by  the  patients  and  seldom  even  noticed  unless 
after  exercise.  Its  progress  followed  that  of  the  principal 
affection,  and  it  was  seldom  extreme  ;  we  have  never  met 
with  more  than  three  cases,  where  the  patient  was  compelled 
to  lie  with  the  head  much  elevated,  or  to  retain  a  sitting  pos- 
ture. After  death,  we  found  nothing  to  explain  this  anom- 
aly ;*  the  heart  was  healthy,  its  orifices  unaffected  ;  there  was 
no  effusion  into  the  cavity  of  the  pleurae. 

244.  In  a  certain  number  of  cases,  dyspnoea  was  only  sen- 
sible one  or  several  months  after  the  origin  of  the  cough.  Most 
frequently  it  commenced  with   it  :  it  even  sometimes  existed 

*  At  the  time  Louis  wrote  this,  he  had  examined  carefully  but  very  few 
cases  of  emphysema  of  the  lungs.     Iq  the  cases  he  has  stated  this  affection 
may  have  existed. —  H.  I.  B. 
Z 


186  SYMPTOMS.  —  DYSPNŒA  ;  [Part  llj 

anteriorly  (in  about  one  tenth  of  the  cases),  and  when  this 
■occurred,  it  was  often  coincident  with  haemoptysis,  which  had 
also  "preceded  the  other  symptoms.  Under  these  circum- 
stances, the  dyspnoea  and  hcemoptysis  were  probably  not 
symptoms  preceding  tubercles  in  the  lungs,  but  the  first  indi- 
cations of  their  existence.  Perhaps  this  was  equally  the  case 
when  no  haemoptysis  was  present  ;  but  that  it  was  so  is  far 
from  being  demonstrated,  for  many  patients  had  their  breath- 
ing more  or  less  affected  from  infmcy,  and  it  was  impossible 
to  date  the  origin  of  phthisis  from  so  remote  a  period  ;  for 
out  of  these  examples,  which  formed  one  ninth  of  the  whole, 
as  great  a  number  had  attained  the  age  of  fifty,  as  among  those 
whose  dyspnœa  had  coincided  with  the  first  symptoms  of  the 
disease. 

245.  The  oppression  was  referred  to  the  central  part  of  the 
chest,  whatever  differences  might  exist  in  the  state  of  the  two 
lungs.  There  were  only  three  exceptions  to  this  fact,  and  in 
these  the  uneasy  sensation  seemed  confined  to  the  side  prin- 
cipally affected. 

246.  Pain  is  not,  we  well  know,  the  most  troublesome 
symptom  in  phthisis  ;  many  were  altogether  exempt,  or  only 
spoke  of  it  when  their  attention  was  directed  to  the  sub- 
ject. A  few  complained  spontaneously  ;  and  it  is  no  doubt 
owing  to  this  absence  of  pain,  and  frequently  its  insignifi- 
cance and  rarity,  conjoined  with  the  insensible  progress  of  the 
symptoms,  that  patients  are  so  completely  deceived  as  to  their 
real  situation.  Without  mentioning  the  pleuritic  symptoms, 
which  compelled  some  of  them  to  ask  advice,  the  greater 
number  had  experienced  pains  either  between  the  shoulders, 
or  on  the  lateral  parts  of  the  thorax.  These  last  were  present 
in  one  third  of  the  examples,  and  were  sometimes  rather  in- 
tense and  of  variable  duration.     They  came  on  at  very  differ- 


Chap.   1.]    PAIN,    ITS    CAUSES    ARE    PLEURISY,    StC. 


187 


ent  periods  of  the  disease,  sometimes  two  or  three  months 
before  death,  when  the  cough  and  expectoration  had  lasted 
one,  two,  or  more  years  ;  at  other  times  (and  these  were  cases 
where  phthisis  had  gone  through  all  its  stages  in  five  or  six 
months),  they  were  present  very  shortly  after  the  appearance 
of  the  first  symptoms  ;  they  sometimes  persisted  only  a  few 
days,  in  others  one  or  many  months  ;  occasionally  they  were 
sufficiently  intense  to  incommode  the  patient,  but  not  to 
compel  him  to  remain  in  bed. 

247.  Most  frequently  there  was  a  direct  correspondence 
of  the  pains  with  the  adhesions,  mostly  cellular,  of  the  lungs 
and  pleuree,  and  very  often  with  the  number  and  size  of  the 
excavations.  And  as  these  two  lesions  were  almost  always 
combined  and  proportionate  to  each  other,  it  would  be  difficult 
to  assign  any  cause  for  the  pains,  if  we  were  not  aware  that 
tubercles  are  developed  in  other  organs  without  pain,  and  as 
those  we  are  now  considering  are  very  similar  to  pleuritic 
pains,  increasing  like  them  by  inspiration  and  cough,  of  an 
acute  and  lancinating  character,  they  are  no  doubt  the  conse- 
quence of  chronic  inflammation.  We  have,  in  a  small  num- 
ber of  instances,  been  able  to  convince  ourselves  in  a  more 
direct  and  positive  manner,  that  this  was  actually  the  cause  of 
the  pains  experienced  by  phthisical  patients.  It  was  in  those 
cases  where  the  lungs  presented  on  one  side  large  excavations 
with  very  slight  adhesions,  on  the  other,  universal  adhesions 
and  no  excavations,  and  when  the  pain  had  been  confined  to 
the  side  where  the  adhesions  were  greatest. 

As,  however,  we  sometimes  see  that  tuberculated  glands  in 
the  neck  and  axilla  (Obs.  9),  become  the  cause  of  pain,  it  is  un- 
doubtedly possible  that,  under  certain  circumstances,  this  may 
be  the  case  with  tubercles  in  the  lungs.  It  is,  in  fact,  what 
we  have  remarked  in  the  only  example  of  encysted  tubercles, 


188  SYMPTOMS.  —  PAINS  IN  CHEST.         [Part  II, 

which  we  have  collected  (Obs.  31).  This  patient  had  expe- 
-  rienced,  during  the  last  fifteen  days  of  her  life,  pains  between 
the  shoulders,  and  no  adhesions  existed  between  the  lungs  and 
pleurae.  This  was  also  the  fact  in  some  instances  of  acute 
phthisis,  where  more  or  less  intense  pains  were  felt  in  the  lat- 
eral parts  of  the  chest,  and  no  trace  of  pleurisy  was  discoverable 
after  death  (Obs.  35,  36).  It  is  then  possible  that,  in  some 
examples,  the  pains  in  the  chest  may  be  owing  both  to  the 
development  of  tubercles  and  the  adhesions  which  follow. 

248.  Twenty-two  patients  assurred  us  that  they  had  never 
felt  any  pain  in  the  thorax,  and  in  the  majority  of  these  ad- 
hesions were  limited  to  the  summit  of  the  lungs,  while  the 
excavations  were  equally  extensive  and  numerous,  as  in  those 
cases  in  which  acute  pains  had  existed.  This  confirms  what 
we  have  said,  as  to  the  most  frequent  cause  of  pains  in  the  chest 
in  phthisis.  We  can,  indeed,  easily  conceive  how  adhesions 
limited  to  the  upper  part  of  the  pleurae  should  not  cause  in- 
convenience, the  corresponding  portion  of  the  thorax  being 
the  least  moveable,  and  pleuritic  pains  appearing  to  be  acute, 
in  consequence  merely  of  the  elevation  of  the  ribs  and  of  the 
expansion  of  the  pulmonary  parenchyma. 

249.  Besides,  if,  as  we  have  remarked  in  the  first  part  of 
this  work  (42),  the  inflammation  of  the  pleurae  and  the  conse- 
quent adhesions  are  often  depending  on  the  influence  of  tuber- 
cles, we  can  understand  why  pains  are  present  in  such  variable 
periods  of  the  disease,  since  tubercles  themselves  are  progres- 
sively developed. 

250.  To  sum  up  our  remarks,  we  find  that  thoracic  pains 
corresponded  with  the  adhesions  of  the  lungs  to  the  pleurae, 
and  not  willi  the  dimensions  or  number  of  the  excavations. 
They  appeared  to  result  from  adhesions  formed  by  chronic 
inflammation  of  the  })leurac,  and   when  these  were  confined  to 


Chap.  1.]    fever;  time  of  its  occurrence.  189 

the  summit  of  the  lungs,  no  pains  were  experienced,  although 
the  excavations  were  considerable.  We  may  add  that  age, 
which  seemed  without  influence  on  the  progress  of  phthisis, 
had  a  very  sensible  effect  on  the  duration  of  pain. 

251.  Fever.  — The  majority  of  patients  having  fever  when 
admitted  into  the  hospital,  we  have  endeavored  to  fix  the 
period  of  its  commencement  with  precision,  and  in  this  we 
think  we  have  succeeded,  whenever  we  have  been  able  to  de- 
termine the  time  at  which  the  rigors,  or  the  alternations  of 
heat  and  cold  commenced,  especially  when  these  were  accom- 
panied from  the  first  with  thirst  or  palpitations.  Taking  this 
epoch  for  our  guide,  the  fever  had  commenced  with  the  earliest 
symptoms  of  phthisis,  and  accompanied  them  through  their 
whole  course  in  rather  more  than  one  fifth  of  the  examples, 
or  in  twenty -one  out  of  ninety-five  cases  which  were  complete 
as  to  the  particular  we  are  now  considering.  Five  among 
these  were  examples  of  acute  phthisis  (Obs.  33,  &ic).  Among 
the  remainder  the  disease  had  lasted  from  five  months  to  three 
years,  including  several  examples  of  simple  phthisis  (Obs. 
27,  29).  In  nineteen  other  cases  the  fever  had  commenced 
in  the  first  half  of  the  disease,  in  those  cases  where  the  affec- 
tion, with  more  or  less  complication,  had  passed  through  its 
different  gradations  in  a  period  varying  from  three  months  to 
five  years.  In  about  three  fifths,  the  febrile  state  was  present 
in  the  second  stage  of  the  disease,  occasionally  only  a  short 
time  before  the  fatal  termination  ;  in  every  instance,  the  mor- 
bid condition  of  the  lungs  was  associated  with  alterations  in  a 
greater  or  less  number  of  organs. 

252.  Since  fever  frequently  commenced  in  the  first  stage 
of  the  complaint,  or  even  from  its  very  beginning,  that  is,  when 
the  lungs  were  still  the  only  organs  affected,  we  must  conclude 


190  SYMPTOMS.  —  fever;        [Part  II, 

that  its  principal  and  often   only  source  was  the  more  or  less 
extensive  alteration  in  the  respiratory  organs. 

353.  Except  in  cases  of  very  acute  or  very  chronic  phthisis, 
it  was  impossible  to  appreciate  the  circumstances  which  thus 
accelerated  or  retarded  the  presence  of  the  febrile  state  ;  and 
to  occupy  ourselves  with  the  investigation  of  this,  as  well  as 
of  the  variations  in  innumerable  other  symptoms,  would  in 
our  opinion  be  endeavoring  to  discover  the  cause  of  differences 
in  tastes,  physiognomy,  and  the  great  varieties  of  em-hon-point 
in  individuals  who  are  in  perfect  health.  We  must  know  how 
to  content  ourselves  with  the  knowledge  of  the  principal  facts, 
and  not  seek  to  explain  every  variation  they  may  present.* 

*  In  the  minds  of  many  fever  and  inflammation  are  inseparable,  but  a 
Trariety  of  considerations  render  this  view  of  the  subject  untenable.  We 
shall  take  advantage  of  the  author's  remarks  in  his  Examen,  page  36,  to 
make  the  reader  acquainted  with  the  evidence  of  facts  on  this  point.  There 
is  no  acute  affection  vi^hich  is  not  preceded  for  a  few  hours  or  days  by  more 
or  less  intense  febrile  movement,  and  during  this  period  no  local  symptoms, 
to  which  it  can  be  attributed,  can  be  observed.  M.  Louis  has  remarked 
this  fact  in  five  twelfths  of  those  attacked  by  erysipelas  of  the  face  ;  in  one 
half  of  the  cases  of  measles  ;  in  a  still  greater  number  of  pneumonias  (com- 
ing on  in  healthy  individuals)  ;  in  one  fourth  of  the  examples  of  cynanclie 
tonsillaris,  and  invariably  preceding  small-pox  in  the  adult.  Not  a  single 
symptom  could  be  detected  capable  of  revealing  an  alteration  of  any  of  the 
organs  presiding  over  our  different  functions.  That  they  were  modified  was 
evident;  but  no  one  could  ascribe  that  modification  to  inflammation.  On 
what  it  depended  we  are  at  present  ignorant.  But  we  are  justified  in  saying 
that  it  is  not  inflammatory.  The  development  of  febrile  movement  in  the 
early  stages  of  phthisis,  when  the  lungs  are  the  only  organs  affected,  is, 
therefore,  no  proof  of  inflammation,  and  we  must  admit  that  the  foj-mer  may 
exist  without  any  appreciable  local  lesion. 

Is  there  not  a  great  analogy  between  this  precursory  febrile  movement, 
terminating  in  eruptions  or  some  local  inflammation,  and  what  in  other 
circumstances  continues,  without  producing  any  particular  affection,  and 
which  we  call  continued  fever  .'    Are  wc  more  justified  in  considering  the 


Chap.  1.]  RIGORS.  191 

254.  Although  rigors  were  among  the  most  frequent  symp- 
toms of  fever,  they  were  not  constant,  being  absent  in  one 
sixth  part,  —  sixteen  times  out  of  ninety-five.  The  patients 
whose  cases  are  excepted,  complained  only  of  great  sensi- 
bility to  cold,  declared  they  never  had  any  shiverings  before 
coming  to  the  hospital,  and  had  been  exempt  from  them 
during  their  residence  there.  This  fact  is  not  more  singular 
than  the  not  unfrequent  absence  of  the  same  symptom  in 
cases  of  phlegmonous  suppuration. 

In  the  greater  number  of  instances,  the  rigors  came  on  every 
evening,  and  seldom  at  any  other  period.  While  in  general 
occurring  only  once,  in  some  cases  they  were  irregularly- 
repeated  several  times  in  the  day  ;  but  we  have  never  ob- 
served two  distinct  rigors  which,  in  the  opinion  of  some 
authors,  daily  recur  at  a  fixed  hour. 

255.  Occasionally,  the  rigors  which  took  place  daily,  at  a 

latter  of  an  inflammatory  nature  than  the  former  ?  Though  perhaps  continued 
fever  is  never  wholly  unaccompanied  by  some  local  disease,  yet  may  not  this 
be  a  very  secondary  cause  of  the  continuance  of  the  fever  ?  The  fact,  that  in 
eruptive  diseases  the  fever  is  arrested  by  the  local  disease  it  tends  to  estab- 
lish, is  remarkable,  and  confirmative  of  the  foregoing  observations.  Inter- 
mittent fevers,  irritative  fevers,  all  admit  of  the  same  reflections.  The  wfant 
of  proportion  between  the  local  disease  and  the  febrile  disturbance,  so  fre- 
quently observed  in  erysipelas,  pneumonia,  &c.,  is  another  argument  for 
their  independence  of  each  other,  or  rather  for  the  possibility  of  fever  ex- 
isting without  inflammation.!  —  Cowan. 

t  I  find  great  difficulty  in  understanding  the  meaning  of  the  translator  in 
the  last  paragraph.  Does  he  intend  by  the  term  "  continued  fever"  to  refer 
to  the  typhoid  affection  .'  If  so,  he  either  thinks  the  typlius  of  London  differ- 
ent from  that  of  Paris,  or  he  has  little  confidence  in  the  results  to  which 
Louis  arrived  when  studying  the  typhoid  disease  in  Paris.  For  the  eluci- 
dation of  this  subject,  the  reader  may  refer  to  Louis  on  Fever,  and  particu- 
larly observe  what  he  says  in  pages  195,  196  and  381  of  vol,  I.  —  H.  I.  B. 


192  SYMPTOMS.  —  fever;        [Part  II, 

particular  hour,  were  sufficiently  inconvenient  to  require  treat- 
ment for  their  suppression.  This  was  sometimes  successful, 
and  at  others  we  merely  lessened  their  duration  or  intensity. 
The  temperature,  however,  remained  always  elevated  in  these 
cases,  and  after  the  rigors  had  been  suspended  during  a  varia- 
ble period  of  time,  they  returned  with  the  same  violence  as 
before  the  administration  of  the  febrifuge.  It  is  also  easy  to 
foresee  that  the  state  in  which  the  stomach  of  phthisical  pa- 
tients usually  is,  forbids  the  indiscriminate  use  of  the  sulphate 
of  quinine. 

256.  The  shiverings  were  generally  followed  by  heat  and 
perspiration.  We  say  generally,  for  perspiration  was  absent 
in  one  tenth  of  those  who  had  chills  ;  and  on  the  other  hand, 
they  sometimes  existed  without  the  rigors  :  this  was  princi- 
pally during  the  night,  when  the  patient  was  asleep.  The 
perspirations  were  so  copious  and  inconvenient  in  some  in- 
stances, that  sleep  was  dreaded.  They  did  not  appear  to 
depend  on  the  state  of  the  other  organs,  and  generally  coin- 
cided with  the  diarrhœa,  which  was  frequently  very  abundant 
when  the  perspiration  was  so  copious  as  to  oblige  the  patient  to 
change  of  clothing  once  or  several  times  during  a  night.  We 
have  in  vain  multiplied  our  questions,  in  order  to  discover 
whether  any  dependence  existed  between  these  phenomena, 
and  whether  they  were  supplementary  of  each  other;  we  have 
never  succeeded  in  afibrding  ourselves  proofs  of  the  balancing 
(balancement)  of  our  functions  insisted  upon  by  some  authors. 
We  have  distinctly  observed,  in  the  course  of  perspirations 
more  or  less  copious,  that  the  diarrhœa  diminished  during  two 
or  three  days  ;  but  it  soon  returned  with  its  previous  violence, 
proving  that  its  variation  was  a  simple  coincidence,  and  not  a 
consequence  of  the  state  of  the  cutaneous  perspiration. 

257.  It  may,  perhaps,  be  urged  that  if  the  "  balancement" 


Chap.   1.]  SUDAMINA.  193 

alluded  to  is  not  real  in  cases  of  phthisis,  it  is  not  less  certainly 
the  fact  in  other  diseases.  But  we  have  equally  failed  to  dis- 
cover it  in  fevers,  rheumatism,  and  in  general  whenever  one 
of  the  two  symptoms  came  on  during  the  existence  of  the 
other;  their  mutual  influence  and  dependence  were  never  evi- 
dent ;  so  that  we  think  ourselves  justified  in  saying  that  when 
the  contrary  appears  to  be  the  case,  it  is  probably  purely 
accidental  and  exceptional.  This  fact  is  not,  perhaps,  without 
importance,  since  the  majority  of  medical  men  regard  the 
*'  balancement"  of  our  functions  as  a  fact  on  which  they  found 
their  practice. 

^58.  The  sudamîna,  so  frequent  after  the  perspirations  in 
continued  fever,  are  much  rarer,  ceteris  paribus,  in  the  course 
of  any  other  disease.  We  have  occasionally  seen  them  in 
phthisis,  but  never  so  numerous  as  in  typhus  fever,  in  which 
the  elevation  of  the  epidermis  is  sometimes  so  general,  that  by 
very  slight  friction  it  might  be  entirely  removed  from  nearly 
the  whole  surface  of  the  body. 

259.  Let  us  remark,  that  these  copious  perspirations  indi- 
cated disorder  in  the  functions  of  the  skin,  as  remarkable  by 
its  intensity  as  duration  ;  that  this  disorder,  whether  sympa- 
thetic or  otherwise,  was  not  the  less  positive,  and  existed 
without  any  sensible  change  of  structure  in  the  organ  itself; 
and  that  thus  a  function  may  be  more  or  less  modified  during  a 
long  period  of  time,  while  the  organ  on  which  it  depends  offers 
no  appreciable  change  of  structure.  We  may  also  observe, 
that  while  facts  are  wanting  to  prove  distinctly  that  diarrhœa 
may  exist  without  appreciable  lesion  of  the  intestinal  mucous, 
membrane,  we  may  presume  this  to  be  the  case,  from  the 
analogy  existing  between  diarrhoea  and  more  or  less  profuse 
perspiration.  Of  this  we  cannot  be  positive,  for  in  our  opinion, 
A  2 


194  SYMPTOMS.  THIRST    AND    APPETITE.       [Part  II, 

analogy  is  only  useful  to  point  out  fresh  subjects  for  investi- 
gation, to  lead  us  to  the  discovery  of  facts,  but  never  to  supply 
them  ;  were  it  otherwise,  we  might  conclude  that  a  thing  really 
existed  because  it  was  possible,  which  is  absurd.  Lastly,  for 
those  who  consider  inflammation  as  the  only  cause  of  func- 
tional derangement,  it  would  be  difficult  to  imagine  this 
phenomenon  in  any  degree  the  cause  of  the  perspirations  of 
phthisical  patients,  whose  skin  remains  pale  and  relaxed  in 
the  midst  of  these  immense  evacuations. 

260.  The  thirst  presented,  like  the  other  symptoms,  very 
remarkable  variations  ;  absent  in  one  fourth  of  the  cases,  it 
was  more  or  less  intense  in  the  rea)ainder  ;  it  preserved  no  con- 
stant relation  with  the  state  of  the  stomach,  intestinal  canal,* 
or  with  the  diarrhoea  ;  it  was  much  more  frequently  propor- 
tionate to  the  fever,  commencing  almost  constantly  with  it, 
accompanying  its  progress,  and  increasing  during  the  evening 
and  night  exacerbations.  In  a  few  instances  the  thirst  had 
been  preceded  by  the  fever. 

261 .  Appetite.  —  When  speaking  of  the  gastric  symptoms, 
we  shall  see   tlie   numerous   variations   in   the   appetite,  for 

*  In  the  majority  of  cases  where  thirst  was  absent,  the  mucous  membrane 
of  the  stomach  was  natural,  and  diarrhœa  had  only  been  present  in  the  last 
period  of  the  disease,  sometimes  thirty,  forty,  and  fifty  days  before  death  ; 
twice  only,  it  had  existed,  with  some  short  intermissions,  nine  months  or 
two  years.  In  .patients,  whose  thirst  was  more  or  less  urgent,  the  gastric 
mucous  membrane  was  nearly  healthy,  or  only  presented  recent  alterations, 
in  rather  more  than  one  half  of  the  examples  ;  diarrhœa  was  nearly  always 
present,  but  preceded  by  the  thirst,  sometimes  twenty  or  more  months,  in 
two  fifths  of  the  cases.  In  other  patients  the  thirst  commenced  with  or 
succeeded  the  diarrhœa,  when  even  the  latter  had  been  violent  (Obs.  4). 
Thirst  was  extremely  ui-gcnt  in  two  individuals  whose  gastro-intestinal 
mucous  membrane  was  Itealthy,  and  who  had  never  had  diarrhœa.  — 
Louis. 


Chap.   I.]  DIARRHŒA.  195 

the  dependence  of  this  on  the   state  of  the  gastric  mucous 
membrane  was  too  evident  to  admit  of  separate  description. 

262.  JDiarrhœa  was  so  frequent,  that  we  feel  justified  in 
considering  it  rather  as  a  symptom  than  a  comphcation,  and 
shall  consequently  not  defer  its  consideration.  Out  of  one 
hundred  and  twelve  patients,  five  only  had  no  diarrhœa.  It 
presented  numerous  gradations  of  intensity  and  duration.  In 
one  eighth  of  the  patients  it  commenced  with  phthisis,  per- 
sisting until  death,  having  lasted  from  five  to  twelve  months. 
In  some  of  those  who  died  after  an  illness  of  four  or  five  years, 
it  was  almost  constant  during  this  long  period  of  time.  In  the 
majority  of  cases,  it  commenced  in  the  second  stage  of  the 
affection  ;  in  others,  towards  the  very  close  of  the  disease  ;  so 
that  we  could  consider  it  under  two  principal  points  of  view, 
viz.,  when  it  occurred  towards  the  close  of  life,  or  when  it 
dated  from  a  period  considerably  anterior  to  death.* 

26-3.  Diarrhœa  towards  the  close  of  life.  —  We  place  in 
this  class  all  those  cases  where  the  diarrhœa  commenced  from 
twenty  to  five  days  before  death.  They  formed  one  fourth  part 
of  the  whole.  In  some  tliis  symptom  was  accompanied  with 
slightly  increased  heat  of  the  skin,  unusual  rigors,  and  variably 
intense  colic  pains.  Most  frequently  nothing  similar  was  ob- 
served. The  stools  were  usually  infrequent.  When  we  have 
examined  the  evacuations,  they  were  yellowish,  pultaceous, 
consisting  of  very  clear  fluid,  free  from  blood  or  mucus,  in 
which  fragments  of  a  variably  consistent  substance  floated. 
The  smell  was  not  very  offensive. 

With  only  one  exception,  the  mucous  membrane  of  both 
intestines  was  the  seat  of  some  alteration.     In  one  half  of  the 


*  The  following  analysis  only  refers  to  ninety-five  cases,  where  the  mu- 
cous membrane  of  both  intestines  was  carefully  examined,  —  Louis. 


196  SYMPTOMS.  -^DIARRHŒA,  &C.  [Part  II, 

individuals  there  were  ulcerations  in  the  small  intestine  or 
colon,  sometimes  in  both  ;  but,  with  one  exception  for  the 
former,  and  two  for  the  latter,  they  were  small  and  kw  in 
number.  In  four  fifths  the  mucous  membrane  of  the  large 
intestine  was  soft  as  mucus,  and  almost  invariably  more  or  less 
red. 

264.  There  was  an  exact  correspondence  between  the 
symptoms  and  the  alterations  to  which  they  might  be  attri- 
buted. For,  if  the  diarrhoea  had  only  preceded  death  by  a 
few  days,  this  seemed  to  be  equally  the  case  with  the  ulcerations 
and  softening  of  the  mucous  membrane  of  the  colon.  In  fact, 
the  ulcerations  were  small,  the  cellular  tissue  lining  them  very 
thin  ;  and,  from  their  natural  tendency  to  increase,  and  that 
of  the  cellular  layer  to  thicken,  we  might  certainly  consider 
them  as  very  recent.  With  regard  to  the  softening,  with  or 
without  redness  of  the  mucous  membrane  of  the  large  intestine, 
we  will  observe,  that  it  was  equally  intense  in  cases  fatal  in 
two  or  three  weeks  from  a  simple  attack  of  dysentery  ;  most 
ordinarily  it  was  evidently  the  result  of  inflanmiation,  which, 
in  its  commencement,  had  in  many  cases  been  attended  with 
slight  febrile  movement,  liquid  stools  and  colic  pains  ;  and 
where  the  pains  and  fever  were  absent,  the  origin  of  the  alter- 
ation must  coincide  with  that  of  the  diarrhœa,  unless  we  admit 
that  colitis  was  always  latent,  which  is  impossible.  Every 
consideration,  then,  seems  to  favor  the  conclusion,  that  the 
small  ulcerations  and  the  softening  we  have  described,  with 
the  inflammation  on  which  they  most  usually  depended,  were 
very  recent  at  the  period  of  death. 

If  we  cannot  imagine  that  so  important  an  alteration  as  the 
pulpy  softening  of  the  mucous  membrane  of  the  large  intes- 
tine could  be  constantly  latent,  we  may  however  conceive  the 
possibility  of  its  being  so,  and  in  fact  we  have  collected  three 


Chap.   1.]  DIARRHŒA    OF    LONG    DURATION.  197 

observations  where  this  was  actually  the  case.  In  one  of 
these,  the  softening  was  conjoined  with  a  tolerably  intense 
red  color  of  the  mucous  membrane.  There  had  been  no 
complaint  of  pain  in  the  abdomen. 

The  diarrhœa  was  less  copious  in  individuals  in  whom 
ulceration  alone  existed,  than  where  softening  was  present  :  — 
a  result  easy  to  be  foreseen,  from  the  difference  in  the  real  im- 
portance of  the  two  alterations. 

265.  The  diarrhœa  of  long  duration  presented  two  prin- 
cipal modifications  :  it  was  either  continued  or  remittent. 

'^QQ.  The  duration  of  the  latter  varied  from  fifteen  months  to 
forty-eight  days.  The  remissions  were  variable,  from  eight  to 
ten,  fifteen,  or  twenty  days;  the  stools  were  generally  scanty  ; 
colic  pains  rare.  Fifteen  of  our  patients  were  examples  of  this. 
In  ten,  the  small  intestine  was  ulcerated  ;  in  six,  this  was  the 
case  with  the  colon,  and,  with  the  exception  of  two  instances, 
for  both  intestines,  the  ulcers  were  small.  The  mucous  mem- 
brane of  the  colon  was  exceedingly  soft  in  ten  others,  and  in 
three  of  these  red  and  thickened  ;  so  that  this  series  of  pa- 
tients offered  nearly  the  same  alterations,  both  as  to  intensity 
and  extent,  as  those  of  the  preceding  series,  in  whom  the 
diarrhœa  commenced,  as  it  were,  only  a  few  days  before 
death.  It  seems  natural,  from  this  alone,  to  suppose  that  the 
lesions  observed  after  death  were  very  secondary  in  the  pro- 
duction of  the  diarrhœa  ;  that  they  originated  in  the  second 
series  as  they  did  in  the  first,  that  is,  towards  the  close  of 
life  ;  and  that  previously  to  this  period  the  diarrhœa  resulted 
from  a  simple  alteration  of  secretion,  which  we  have  already 
remarked,  appeared  to  be  the  case  with  the  perspirations. 

267.  Chronic  and  continued  diarrhœa  lasted  from  one  to 
twelve  months,  sometimes  even  longer.  It  was  more  or  less 
violent,   and  generally   accompanied  with   colic.     In  one  in- 


198  SYMPTOMS.  CONTINUED    DIARRHŒA.       [Part  II, 

Stance,  where  it  was  prolonged  five  months  (Obs.  4),  there 
were  not  less  than  from  twelve  to  fifteen  stools,  often  copious, 
during  the  day.  Out  of  forty-one  patients,  affected  in  this 
way,  thirty-five  had  ulcerations  in  the  small,  and  thirty-one  in 
the  large  intestine.  Twelve  times  the  ulcerations  of  the  small 
intestine  occupied  its  whole  length.  They  were  of  consider- 
able size,  and  about  an  inch  in  diameter  in  thirteen  patients, 
whether  they  were  universally  or  only  partially  distributed. 
There  were  nineteen  examples  of  extensive  ulceration  of  the 
large  intestine,  and  thirty  of  softening  of  its  mucous  membrane. 
The  latter  was  red  in  seventeen  of  these.  Thus,  after  long 
continued  diarrhoea,  we  found  extensive  and  numerous  ulcera- 
tions; that  is,  morbid  alterations  similar  to  what  we  find  when 
diarrhoea  has  been  chronic  but  with  occasional  intermissions, 
though  in  the  former  case  the  ulcerations  were  much  more 
intense,  and  evidently  of  longer  duration. 

268.  Large  ulcerations  existed  in  both  intestines,  in  six 
patients  in  whom  the  diarrhœa  had  been  copious  and  contin- 
ued during  two,  three,  five,  and  eleven  months.  In  others, 
they  were  only  considerable  in  the  small  intestine  or  colon. 
If  in  the  small,  the  diarrhœa  was  not  the  less  chronic  and  con- 
tinuous ;  an  evident  proof  that  it  cannot  be  considered  as  ex- 
clusively resulting  from  alterations  in  the  large  intestine.  We 
must,  however,  admit  that  the  latter  was  its  principal  source 
in  phthisis,  for  the  mucous  membrane  of  the  colon  was  much 
more  frequently  softened  and  inflamed  than  that  of  the  small 
intestine.  What,  however,  renders  it  still  more  improbable 
that  the  affections  of  the  colon  are  the  only  cause  of  diarrhœa, 
is,  that  in  continued  fever,  where  this  symptom  is  very  seldom 
wanting,  the  chief  and  often  only  alteration  of  the  alimentary 
canal  is  in  the  small  intestine. 

269.  To  be  able  to  predict  with  sonje  certainty  the  exist- 


Chap.   1.]  EMACIATION.  199 

ence  of  large  and  numerous  ulcerations,  it  is  not  only  requisite 
that  the  diarrhœa  should  have  been  chronic  and  continuous, 
but  that  the  stools  should  have  been  frequent  ;  for,  in  many 
instances  where  this  last  condition  was  wanting,  although  the 
diarrhœa  had  continued  many  years  uninterruptedly,  the  ulcer- 
ations were  very  inconsiderable.*  But  we  have  never  met 
with  an  example  where  the  diarrhœa  was  chronic,  continuous, 
and  when  at  the  same  time  the  stools  were  numerous,  without 
large  intestinal  ulcerations.  The  certainty  of  the  diagnosis 
would  be  still  farther  increased  by  the  inspection  of  the  evac- 
uations. For,  in  accordance  with  what  we  have  remarked  in 
the  former  part  of  this  work  (143),  their  color  was  greatly 
changed,  and  their  odor  similar  to  that  of  animal  substances 
some  time  in  maceration,  when  the  ulcerations  were  extensive 
and  numerous. 

270.  If  those  in  the  rectum  were  small  they  exerted  no  in- 
fluence on  the  diarrhœa.  If  they  were  extensive,  and  partic- 
ularly if  situated  close  to  the  anus,  the  dejections  were 
extremely  frequent,  mucous,  accompanied  with  tenesmus, 
sometimes  streaked  with  blood,  and  generally  involuntary. 
The  loss  of  strength  and  flesh  was  also  proportionate  to  the 
number  and  frequency  of  the  stools  in  all  the  cases. 

271.  Emaciation  was  present  in  one  half  of  the  cases  from 
the  commencement  of  the  first  symptoms,  whether  the  pro- 
gress towards  the  fatal  termination  was  rapid  or  slow,  varying 
for  example  from  five  months  to  three  years.  In  a  very  few 
instances  it  coincided  with  the  first  appearance  of  the  diarrhœa 
or  loss  of  appetite,  although  the  gastric  mucous  membrane  was 
often  perfectly  sound,  or  its  alterations  still  recent  at  the  mo- 

*  These  facts  confirm  what  we  have  already  said,  viz.  that  vitiated  secre- 
tions are  probably  in  many  instances  a  cause  of  diarrhœa.  —  Louis. 


200  SYMPTOMS.  —  EMACIATION.  [Part  II, 

nient  of  death.  In  one  third,  it  seemed  to  originate  with  the 
fever  ;  its  origin,  therefore,  in  the  majority  of  cases,  could  not 
be  attributed  either  to  the  fever,  diarrhoea,  loss  of  appetite,  or 
to  a  morbid  state  of  the  gastric  mucous  membrane  ;  we  are 
then  obliged  to  ascribe  it  to  the  more  or  less  extensive  altera- 
tion of  the  pulmonary  parenchyma  interfering  with  the  nutri- 
tive function.  The  diarrhœa  once  established,  the  emaciation 
proceeded  rapidly.  The  state  of  the  gastric  mucous  mem- 
brane exerted  also  an  active  influence,  and  unless  some 
accident  to  the  brain  or  lungs,  a  perforation  of  them,  for  ex- 
ample, shortened  the  patient's  life,  the  marasmus  became 
extreme. 

Loss  of  flesh  can  furnish  to  the  physician  very  useful  indi- 
cations as  to  the  diagnosis  in  cases  of  latent  phthisis  ;  that  is, 
when  the  patients,  without  experiencing  any  local  symptoms, 
are  harassed  by  continued  fever  of  some  duration,  and  accom- 
panied with  dyspnœa  and  emaciation.  Under  these  circum- 
stances it  is  rare  that  the  seat  of  the  disorder  is  not  in  the 
lungs,  and  the  affection  tuberculous.  It  is  an  additional  reason 
for  having  recourse  to  all  the  means  in  our  power  for  discover- 
ing the  exact  state  of  the  lungs  in  such  cases. 

272.  Emaciation  was  evident  in  almost  all  the  tissues.  The 
adipous  ultimately  disappeared  almost  entirely  ;  the  skin  itself 
became  thinner  ;  the  muscles  were  not  less  diminished  in  vol- 
ume. We  have  already  spoken  of  the  state  of  the  heart  ; 
but  the  change  was  much  more  evident  in  the  muscles  of 
volition  ;  among  these,  the  flat  muscles,  the  temporals,  and 
those  covering  the  parietes  of  the  chest,  he.  were  in  the 
majority  of  individuals  not  one  third  of  their  natural  thickness. 
The  muscular  layer  of  the  stomach  also  appeared  thinner. 
The  uterus  was  evidently  in  several  instances  smaller  than 
natural,  &:c. 


Chap.  2.]  DIAGNOSIS.  FIRST    PERIOD.  201 

273.  The  face  had  no  particular  expression.  In  patients 
whose  complexion  was  habitually  florid,  it  became  gradually 
pale.  In  some  îev^  instances  its  color  increased,  which  ap- 
peared owing  to  peculiar  circumstances  (Obs.  55).  The 
cheeks  were  not  red  in  the  intervals  of  febrile  exacerbation, 
and  the  slight  blush  which  they  then  assumed  was  similar  to 
what  we  see  in  the  course  of  other  chronic  affections  under 
similar  circumstances. 

The  remainder  of  the  body  shared  in  the  paleness  of  the 
face.  Very  rarely  there  was  slight  oedema  round  the  ankles, 
and  still  more  rarely  throughout  the  whole  of  the  lower  ex- 
tremities (Obs.  3).  Sometimes  one  hand  and  the  fore-arm 
were  slightly  infiltrated,  which  announced  a  serous  effusion  in 
one  side  of  the  chest.  But  none  of  these  symptoms  were 
peculiar  to  phthisis,  and  were  not  more  frequent  in  its  course 
than  in  that  of  other  chronic  diseases. 


CHAPTER   II 

DIAGNOSIS. 


Auscultation  and  percussion  are  the  means  by  which  we 
may  arrive  at  the  diagnosis  of  phthisis.  But  as  the  results  of 
auscultation  and  percussion  differ  at  the  different  periods  of 
the  disease,  we  shall,  for  the  sake  of  the  diagnosis  as  well  as  for 
the  history  of  the  progress  of  the  affection,  separately  consider 
the  results  obtained  at  two  periods,  one  previous  to,  and  the 
other  succeeding  the  formation  of  tubercular  excavations. 
B  2 


202  SYMPTOMS.  —  DIAGNOSIS,  FIRST  PERIOD;  [Part  11^ 

274.  First  period.  —  The  diagnosis  in  this  period,  as  in 
that  corresponding  to  it  in  other  chronic  diseases,  is  often  un- 
certain ;  but  we  beUeve  that  by  a  careful  examination  of  the 
facts,  we  may  frequently  acquire  a  very  high  degree  of  pro- 
bability. We  will  glance  at  some  of  the  principal  circum- 
stances. 

In  the  greater  number,  the  cough  came  on  without  any 
evident  cause,  and  frequently  one  or  several  months  elapse 
without  expectoration.  This  absence  of  any  obvious  cause, 
and  this  dryness  of  the  cough  are  of  themselves  very  remark- 
able, differing  from  what  occurs  in  simple  bronchitis. 

Whether  the  expectoration  be  present  from  the  commence- 
ment, or  only  from  a  more  advanced  period  of  the  disease, 
it  at  first  is  clear,  frothy,  white,  and  forms  a  fluid  very  analo- 
gous to  saliva,  and  it  retains  these  characters  for  a  longer  or 
shorter  time,  which  is  not  the  case  in  simple  pulmonary 
catarrh. 

So,  likewise,  thoracic  pains,  when  present  in  the  latter 
affection,  are  rarely  felt  except  in  the  middle  of  the  sternum, 
while  in  phthisis  they  are  not  only  frequent,  but  are  situated 
in  the  sides  of  the  chest  and  between  the  shoulders,  also  with 
other  characters  to  distinguish  them  from  those  in  bronchitis. 
Conjoined  with  the  preceding  symptoms,  pains,  such  as  we 
have  described,  seem  to  us  strongly  indicative  of  tubercles  in 
the  lungs. 

On  the  other  hand,  out  of  twelve  hundred  patients,  not  in- 
cluding cases  of  amennorrhœa,  or  persons  suffering  from  ex- 
ternal violence  upon  the  chest,  not  one,  with  the  exception  of 
phthisical  patients,  had  experienced  hcemopiysis  ;  so  that  the 
occurrence  of  this  symptom  during  this  period,  preceded  or 
followed  by  thoracic  pains,  cough  and  expectoration  havin»- 
the  characters  we  have  described,  renders  the  presence  of 


Chap.  2.]  AUSCULTATION    AND    PERCUSSION.  203 

tubercles  in  the  lungs  almost  certain.  And  as  the  combina- 
tion of  these  symptoms  is  rather  frequent,  we  see  how  it  is 
possible  in  many  instances  to  diagnosticate  phthisis  at  a  very 
early  period. 

275.  There  is  also  very  often  in  a  limited  space  less  sound  on 
percussion  under  one  of  the  clavicles  than  under  the  other  ;  and 
as  tubercles  are  almost  invariably  developed  from  the  summit 
to  the  base  of  the  lungs,  this  fact,  if  well  determined,  greatly 
increases  the  certainty  of  our  diagnosis.  The  respiratory 
murmur  is  also  rather  weaker  in  the  point  corresponding  to  the 
dulness  on  percussion  than  in  any  other  portion  of  the  chest  ;* 

*  It  may  be  here  useful  to  mention  another  result  of  auscultation,  on 
which  the  attention  of  medical  men  has  only  been  lately  fixed,  and  which 
was  first  signalized  by  Dr.  Jackson,  of  Boston,  in  the  wards  of  M.  Louis, 
who  has  twice  amply  confirmed  its  value  as  an  additional  aid  in  diagnosis. 
We  refer  to  the  study  of  the  expiration.  In  health  this  is  scarcely  and 
sometimes  not  at  all  sensible,  and  never  seems  to  occupy  the  seat  of  inspira- 
tion, but  is  evidently  at  a  distance  from  the  surface  in  the  larger  bronchia, 
and  very  feeble.  But  when  the  density  of  the  lung  is  increased,  the  ex- 
piration becomes  gradually  more  and  more  distinct  and  superficial,  till  it 
resembles  a  second  inspiration,  and  frequently  is  alone  heard  ;  without 
accurate  comparative  examination,  it  might  easily  be,  and  no  doubt  often  has 
been  mistaken,  for  the  inspiratory  murmur.  What  renders  this  sign  pecu- 
liarly valuable  is,  that  the  change  in  the  expiration  precedes  that  of  the 
inspiration,  and  consequently  the  modification  is  principally  applicable  to 
the  early  periods  of  the  disease,  when  correct  diagnosis  is  so  important.  1 
have  frequently  seen  M.  Louis,  from  this  symptom  alone,  decide  on  the  ex- 
istence of  induration  of  the  lung,  when  it  could  neither  be  detected  by  per- 
cussion or  modified  inspiration.  Dr.  Jackson  has  also  proposed  a  plessimeter 
ot  India-rubber,  which,  from  its  yielding  no  sound  of  its  own,  and  protecting 
the  patient  from  the  pain  which  the  use  of  the  finger  or  a  hard  substance 
often  occasions,  possesses  decided  advantages.  M.  Louis  agrees  fully  in  its 
utility  and  efficiency  ;  the  piece  employed  should  be  about  a  quarter  of  an 
inch  thick  and  an  inch  square. t  —  Cowan. 

t  This  subject  is  doubtless  a  very  interesting  one  to  any  individual  who  is 
desirous  of  an  early  diagnosis  in  phthisis.     I  think,  however,  that  the  exist- 


204  SYMPTOMS.  —  DIAGNOSIS,  FIRST  PERIOD  ;  [Part  II, 

a  mucous,  sonorous,  or  crepitating  râle  is  occasionally  heard, 
which  is  either  confined  to  this  region,  or  extends  a  very 
short  distance  beyond  it,  and  is  of  a  different  character  ;  so 
that  the  alterations  in  the  respiration  and  clearness  of  sound 
on  percussion,  like  the  development  of  tubercles,  take  place 
from  the  summit  to  the  base  of  the  chest,  and  are  confirmative 
of  the  diagnosis  founded  on  the  previous  symptoms. 

276.  When  we,  therefore,  meet  in  the  same  individual  the 
dry  cough  which  has  existed  a  variable  space  of  time,  and  in 
many  instances  has  come  on  without  apparent  cause,  accom- 
panied with  clear,  mucilaginous  kinds  of  expectoration,  pains 
in  the  sides  of  the  chest  or  in  the  back,  haemoptysisat  the  com- 
mencement or  during  the  progress  of  the  cough,  dulness  of 
sound  under  one  or  both  clavicles,  diminution  or  any  other 
alteration  of  the  respiratory  murmur  in  the  same  point,  while 
the  remainder  of  the  lungs  is  healthy,  we  may  be  certain  of 
the  presence  of  unsoftened  tubercles.  The  dyspnoea,  the  loss 
of  appetite,  the  emaciation,  the  sensibility  to  cold,  and  often 
the  chills,  &c.,  which  are  present  in  this  first  period,  assist  our 
diagnosis,  but  could  not,  independently  of  the  preceding  symp- 
toms, confirm  it. 

ence  of  a  prolonged  expiration  at  the  apex  of  the  lungs,  as  a  sign  of  the  ex- 
istence of  tubercles,  is  not  yet  perfectly  demonstrated.  I  would  i-emark 
at  this  time,  that  I  have  often  found  at  the  same  time  that  the  expiration  be- 
gins to  become  longer  the  inspiration  shortens,  both  in  phthisis  and  pneu- 
monia. How  far  shortening  of  the  inspiration  may  be  of  use  in  diagnosis,  I 
cannot  as  yet  say,  as  my  means  of  examination  have  been  limited  since  I  first 
noticed  the  fact.  Meanwhile  I  leave  it  to  others  having  larger  opportunities 
to  investigate  it,  but  I  would  suggest  the  necessity  of  always  analyzing  the 
respiration  so  far  as  to  describe  the  inspiration  and  expiration,  and  to  mark 
their  respective  durations,  and  the  peculiar  râles  heard  during  each.  — 
H.  I.  B. 


Chap.  2.]  AUSCULTATION    AND     PERCUSSION.  205 

277.  Many  of  our  observations  (Obs.  10,  35,  Stc),  and 
annong  others  the  following,  are  illustrative  of  what  we 
advance. 


TENTH     OBSERVATION.    (Bis.) 

A  BOOK-BINDER,  sBt.  16,  tall,  habitually  thin,  entered  the 
hospital  of  La  Charité,  March  23d,  1825.  Hair,  black  j 
skin,  fresh  colored  ;  he  was  not  subject  to  sickness  of  any  kind, 
or  cold.  He  dated  his  present  illness  fifteen  days  ;  he  had  ex- 
perienced at  the  commencement,  without  any  apparent  cause, 
great  lassitude,  with  violent  rigors,  and  a  cough  accompanied 
by  a  small  quantity  of  clear  expectoration.  These  symptoms 
had  continued  ;  pains  in  the  precordial  region  were  excited  by 
cough,  and  on  the  eighth  day  he  expectorated  a  little  blood. 
Bowels,  costive  ;  thirst,  not  urgent  ;  very  little  appetite. 
The  general  weakness  had  much  increased. 

March  25th.  Expression,  rather  animated,  a  little  less  how- 
ever than  usual  ;  considerable  debility  ;  he  had  walked  with 
difficulty  to  the  hospital.  Cough,  usually  dry,  rarely  ac- 
companied with  a  clear,  mucous,  spumous  expectoration  ; 
it  no  longer  excited  pain  in  the  precordial  region.  Per- 
cussion of  left  part  of  chest,  natural,  but  rather  dull  for 
two  inches  under  the  right  clavicle,  where  there  was  a 
slight  crepitating  râle.  Respiration,  rather  confused  pos- 
teriorly in  the  corresponding  point,  but  elsewhere  natural. 
No  oppression  ;  but  he  cannot  repeat  many  words  without 
drawing  his  breath.  Pulse,  one  hundred  and  six,  regular  ; 
heat  of  skin,  natural  in  the  morning,  elevated  towards 
noon,  and  accompanied  vi^ith  perspiration  at  night.     Tongue, 


S06  SYMPTOMS. DIAGNOSIS,    FIRST   PERIOD;    [Part  II, 

very  moist,  natural  on  edges,  a  little  yellowish  in  the  centre  ; 
Tery  little  appetite  ;  thirst,  moderate  ;  abdomen,  not  painful  ; 
three  liquid  stools  without  pain  the  previous  evening.  The 
patient  is  quite  tranquil,  and  attitude  in  bed  is  natural. 

(Infusion  of  violets  ;  gum  potion  ;  V.  S.   §  viij.  ;  diet.) 

Thedisease  continued  to  progress,  and  up  to  the  31st  of 
May,  the  day  of  his  death,  the  following  is  the  result  of  our 
observations.  He  coughed  very  little  during  the  first  month, 
but  rather  more  frequently  afterwards  ;  the  expectoration  was 
of  no  marked  character,  and  so  scanty  that  it  was  generally 
dried  up  in  the  spitting  vessel.  There  were  occasionally  pains 
in  the  leftor  right  side  of  the  chest,  lasting  for  a  short  time. 

During  the  latter  half  of  May,  the  breathing  was  always 
somewhat  oppressed.  On  the  i^9th  of  March  there  was  con- 
siderable resonance  of  voice  under  the  right  clavicle.  On  the 
8th  of  April  the  respiration  in  the  same  region  was  almost 
tracheal,  both  anteriorly  and  posteriorly,  and  accompanied  by 
a  gurgling,  which  became  a  coarse  crepitation  two  inches  be- 
low the  clavicle  ;  this  râle  extended  to  a  very  short  distance. 
On  the  left  part  of  chest  the  respiration  appeared  natural, 
except  superiorly  and  posteriorly,  where  there  was  an  occa- 
sional crackling  sound.  On  the  13th,  great  resonance  of  voice 
under  both  clavicles.  On  the  28th,  pectoriloquy  was  evident 
in  every  direction  round  the  summit  of  the  right  lung;  it  was 
doubtful  on  the  left  apex.  No  other  evident  change  in  the 
results  of  auscultation,  which  was  performed  many  times,  oc- 
curred before  death. 

From  the  29th  of  March,  percussion  under  the  right  clavi- 
cle became  gradually  duller,  and  extended  over  a  larger  space. 
The  heat  of  the  skin  was  considerable  in  the  evening  ;  night 
perspirations  almost  daily,  and  not  preceded  by  rigors.  On 
the  25th,  pulse,  ninety-five  ;  it  increased  shortly  afterwards, 


Chap.  2.]  AUSCULTATION    AND    PERCUSSION.  207 

and  never  again  fell  below  one  hundred;  and  from  the  15th 
of  May  it  was  one  hundred  and  twenty. 

Very  little  thirst  ;  appetite,  always  feeble.  The  food  con- 
sisted of  some  rice  creams,  with  sometimes  an  e^v.  Bilious 
vomitings  took  place  on  the  11th  and  12th  of  May,  and  did 
not  occur  afterwards;  the  epigastrium  was  never  painful; 
stools,  scanty  and  rather  fluid. 

May  26th.  Œdematous  state  of  left  cheek,  hand  and  fore- 
arm ;  this  gradually  increased  until  death.  On  the  morning 
of  the  30th,  the  countenance  was  slightly  changed  ;  there  was 
an  expression  of  terror,  without  doubt  to  be  attributed  to  the 
extreme  dyspnoea  which  then  existed.  Death  took  place  at 
three  o'clock  the  next  day,  preceded  by  very  slight  delirium. 

Opening  of  the  corpse  twenty-nine  hours  after  death. 

Exterior.  — Slight  œdema  of  the  lower  extremities,  also 
of  the  fore-arm,  and  face  on  the  left  side  ;  limbs,  flaccid. 

The  head  was  not  examined. 

Neck. — Mucous  membrane  of  epiglottis,  of  a  pale  pink 
color,  without  other  alteration.  A  superficial  ulceration  at  the 
convergence  of  the  vocal  cords.  Trachea,  of  a  bright  red  color 
throughout,  with  numerous  small  oval  ulcerations,  of  about  a 
line  in  breadth,  as  if  portions  of  the  membrane  had  been  artifi- 
cially removed  ;  the  latter  was  elsewhere  of  natural  consist- 
ence and  thickness. 

Chest.  —  Some  long  and  thick  adhesions  at  the  summit 
of  both  lungs,  especially  that  of  the  right.  About  a  pint  of 
clear  serum  in  each  pleura.  The  whole  of  the  upper  right 
lobe  was  of  considerable  density,  presenting  at  its  summit 
tuberculous  excavations  communicating  whh  the  bronchia,  and 
none  of  them  were  larger  than  a  small  nut.  Their  parietes 
were  not  lined  by  false   membrane,  but  formed  by  a  semi- 


208  SYMPTOMS. — DIAGNOSIS,  FIRST  PERIOD;  [Part  II, 

opaque  substance,  homogeneous,  of  a  greyish  and  greenish 
aspect,  tolerably  firm,  not  granulated,  and  yielding  by  pressure 
a  similarly  colored  fluid,  which  was  turbid.  This  induration, 
which  existed  in  the  whole  upper  lobe,  presented  various 
small  excavations,  and  numerous  irregularly  defined  tubercles. 
These  last  existed,  without  excavations,  in  the  upper  part  of 
the  lower  lobe,  the  base  of  which  was  slightly  congested,  and 
contained  some  semi-transparent  granulations.  Similar,  but 
less  extensive  lesions  in  the  left  lung.  Bronchia  of  right 
lung  redder  than  those  of  the  left  ;  they  were  slightly  ulcer- 
ated.    Heart,  of  good  size,  and  aorta  healthy. 

Abdomen. — A  quart  and  a  half  of  limpid,  rust-colored 
serum  in  the  peritoneal  cavity.  Œsophagus,  healthy,  except 
for  about  an  inch  at  its  cardiac  extremity,  where  it  was  much 
thinned  and  easily  torn  ;  internally  it  had  a  bluish  tint,  and  its 
thin  mucous  membrane  was  wanting  over  a  space  of  half  an 
inch.  The  stomach,  which  was  rather  voluminous,  and  con- 
taining a  small  quantity  of  turbid  fluid,  had  over  its  upper  portion 
and  great  cul-de-sac  a  bluish  tint,  like  that  of  the  lower  part  of 
the  œsophagus,  in  a  continuous  surface  about  equal  to  the  palm 
of  the  hand  ;  the  same  color  reached  to  within  two  inches  of 
the  pylorus  in  bands,  three  or  four  lines  wide,  and  as  many 
inches  long.  The  corresponding  mucous  membrane  was  ex- 
tremely thin,  and  soft  as  mucus,  rather  viscous  and  semi-trans- 
parent, here  and  there  it  was  destroyed.  In  the  intervals  of 
the  colored  portion  it  was  a  little  softened,  but  of  naturaJtint. 
Duodenum,  sound.  The  mucous  membrane  of  the  small  in- 
testine was  of  its  natural  color  and  consistence,  slightly  soften- 
ed, and  presented  in  its  last  two  thirds  about  forty  small  ulcera- 
tions, from  two  to  three  lines  in  surface,  and  almost  all  upon  the 
patches.  Their  lining  and  their  circumference,  for  the  space 
of  two  lines,  were  greyish  and  formed  by  the  submucous  layer, 


Chap.   2.]         AUSCULTATION    AND    PERCUSSION.  209 

slightly  thickened.     The   mucous   membrane  of  the  large  in- 
testine was  in  contact  with  some   puliaceous,  yellowish  fseces. 
It  was  every  where  softened,  and  especially  so  in  the  caecum, 
where  it  was  not  more  consistent  than  mucus  ;  it  offered  nu- 
merous ulcerations,  from  half  an  inch  in  surface  and  upwards, 
both  in  the   caecum,   ascending  and  transverse  colon.     Their 
edges  were  prominent,   their  bottom  blackish,  and  formed  by 
the  slightly    thickened   submucous  layer.       Opposite  to  the 
ileo-csecal  valve  there  was  a  greyish  patch,  partially  ulcerated, 
in  which  was  rather  a  large   number  of  tuberculous  granula- 
tions,    imbedded,  as   it  were,   in  the  submucous  membrane. 
This  last  was  more  or  less   thickened   throughout  the  whole 
course  of  the  intestine.     Many  of  the  mesenteric  glands  nearly 
equally   scattered   through    the    mesentery    were  rough,  in- 
creased in  volume,  reddish  colored,  and   in   part  composed  of 
crude,  tuberculous  matter.     The  other  organs  of  the  abdo- 
men  were   healthy.     The   bile  of  the   gall-bladder,   darkish 
colored  and  very  viscous. 

This  observation  is  one  of  those  which  speaks  most  strongly 
in  favor  of  auscultation  and  percussion.  At  our  first  examina- 
tion of  the  patient,  on  the  seventeenth  day  of  the  disease,  he 
might  have  been  considered  laboring  under  simple  catarrh. 
But  the  absence  of  all  apparent  causes,  and  the  slight  haemop- 
tysis which  had  occurred  on  the  eighth  day,  having  induced 
us  carefully  to  examine  the  chest,  we  found  that  the  respira- 
tory murmur  below  the  right  clavicle  was  feeble  and  mingled 
with  a  crepitating  râle  confined  to  this  region;  that  the  percus- 
sion was  also  duller  there  than  elsewhere  ;  and  from  these  symp- 
toms we  did  not  hesitate  to  consider  the  patient  as  phthisical, 
although  his  general  health,  and  the  short  time  which  had 
elapsed  from  the  commencement  of  the  affection  appeared 
c  2 


210     sîwpTows. — DIAGNOSIS,  SECOND  PERIOD;   [Part  II, 

little  favorable  to  such  a  diagnosis.  It  v^'as,  however,  soon  con- 
finned  by  tlie  progress  of  the  symptoms,  the  resonance  of  the 
voice  and  pectoriloquy  under  the  right  clavicle  ;  and,  if  we  recol- 
lect the  mode  of  tubercular  development,  it  will  be  granted  that 
our  diagnosis  was  not  less  easy  than  rational.  However,  not 
to  distract  the  attention  from  the  principal  object  of  this  chap- 
ter, we  shall  content  ourselves  with  remarking,  that  the  softened 
state  and  diminished  thickness,  with  partial  destruction  of  the 
gastric  mucous  membrane  were  latent;  that  bilious  vomiting 
only  occurred  during  two  days,  which  of  itself  was  insufficient 
to  characterize  the  lesion  which  existed  ;  the  same  remark 
may  be  made  as  to  that  of  the  lower  portion  of  the  œsophagus. 

278.  Second  period  of  Phthisis.  — The  sputa,  which  be- 
come somewhat  thick  towards  the  close  of  the  first  stage,  are 
greenish,  and  marked  with  whitish  lines  on  their  surface,  at  the 
commencement  of  the  second.  They  have  not  yet  any  definite 
form,  but  they  soon  become  thicker,  rounded,  and  often  rag- 
ged (lacérés)  in  their  circumference,  characters  which  are  pecu- 
liar to  phthisis  (226).  Thoracic  pains  begin,  or  if  previously 
existing,  are  sometimes  more  intense,  and  are  of  equal  impor- 
tance. Hssmoptysis  is  pretty  frequent,  and  is  not  accom- 
panied by  any  peculiar  circumstance  ;  so  that  among  the  local 
symptoms,  the  sputa  alone  differ  in  the  two  periods  of  the 
disease. 

279.  The  results  of  percussion  in  this  period  are  not  less 
decisive  than  in  the  other.  In  fact,  we  have  seen  that  in  one 
third  of  the  cases,  the  upper  lobe  of  one  or  the  other  lung 
was  entirely  converted  into  tubercles,  grey  substance,  and  into 
excavations  successively  smaller  from  the  summit  to  the  base. 
When  this  was  the  case  the  corresponding  part  of  the  chest  was 
dull  on  percussion,  while  it  was  clear  every  where  else.  This 
state  of  things,  of  itself,  and  without  other  investigation,  vi^ould 


Chap.  2.]      PECULIAR    (PELOTONES)      SPUTA,    &,C.  21  I 

almost  be  sufficient  to  characterise  phthisis.  By  means  of 
this  alone  in  subjects  who  were  but  slightly  emaciated,  and  in 
whom  the  aflection  had  gone  on  slowly,  we  have  been  able 
many  times  to  recognise  the  existence  of  tubercles  without 
any  interrogatory,  or  examination  of  the  sputa,  and,  more- 
over, the  autopsy  has  verified  the  truth  of  our  diagnosis. 

280.  At  the  same  time  that  the  sputa  become  striated  with 
yellowish  hues  and  denser,  the  respiratory  murmur  is  strong, 
coarse,  or  even  tracheal  under  the  clavicles,  in  the  part  cor- 
responding to  that  in  whicli  are  found  after  death  the  largest 
excavations.  To  this  is  frequently  conjoined  either  a  crepita- 
ting râle  (resembling  the  sound  produced  by  bending  dry 
basket-work,  or  a  very  dry  piece  of  sole  leather),  or  the  true 
gurgling.  The  voice  soon  becomes  resonant,  and  this  is 
shortly  replaced  by  pectoriloquy.  The  space  in  which  these 
different  changes  take  place  is  at  first  limited,  but  it  daily  in- 
creases ;  and  in  some  instances,  where  the  whole  of  the  upper 
lobe  is  converted  into  numerous  excavations,  the  respiration  is 
coarse,  and  more  or  less  tracheal  throughout  its  whole  extent. 
The  gurgling  and  other  râles  are  also  present,  but  their  char- 
acters, as  well  as  those  of  the  tracheal  respiration,  diminish  as 
we  recede  from  the  clavicle,  thus  coinciding  with  the  succes- 
sive development  of  tubercles,  and  of  their  evacuation  when 
softened.  The  pectoriloquy  becomes  daily  more  distinct, 
without,  however,  existing  throughout  the  whole  of  that  part 
of  the  thorax  which  corresponds  to  the  upper  lobe. 

281.  These  shades  of  difference  in  the  characters  of  the 
râles  and  tracheal  respiration,  which  take  place  from  the  sum- 
mit to  the  base  of  the  lungs,  are  most  important  for  the  accu- 
racy of  our  diagnosis.  They  must  fix  our  attention  not  less 
than  the  local  symptoms  we  have  described  ;  for,  although 
pectoriloquy  and   tracheal   respiration   prove  the  existence  of 


2         SYMPTOMS. DIAGNOSIS,    SECOND    PERIOD  J    [Part  IV, 

an  excavation,  they  do  not  indicate  its  nature  ;  and  if  we  at 
once  concluded,  from  the  mere  existence  of  these  symptoms, 
that  the  case  was  phthisis,  we  should,  at  least  occasionally, 
be  led  into  error,  as  the  following  observation  will  prove. 


ELEVENTH     OBSERVATION. 

A  DAY  laborer,  set.  59,  of  middle  height,  feeble  constitution, 
had  been  subject  to  shortness  of  breath  from  childhood, 
which  had  considerably  increased  the  last  ten  years,  during 
which  he  had  been  laboring  under  bronchitis.  This  last 
was  less  intense  during  the  summer,  was  very  troublesome 
in  the  winter,  and  then  accompanied  by  emaciation.  For 
the  last  six  months,  gradual  diminution  of  both  cough  and 
appetite  ;  but,  one  month  before  entering  the  hospital,  the 
anorexia  had  been  complete,  the  cough  had  become  more 
troublesome,  and  the  debility  more  considerable  ;  he  had 
entirely  ceased  his  occupations.  He  had  never  complained 
of  pains  in  chest,  and  never  had  had  haemoptysis. 

November  30th,  1824,  the  day  after  his  admission,  face, 
pale  ;  lower  extremities,  slightly  infiltrated  ;  walks  slowly, 
and  with  difHculty  ;  cough,  moderate  ;  expectoration,  opaque, 
greenish,  not  striated  ;  respiration,  almost  perfectly  tracheal, 
and  with  a  coarse,  crepitating  râle  under  right  clavicle,  and 
posteriorly  in  the  corresponding  point  ;  great  resonance  of 
voice  and  indistinct  pectoriloquy  in  the  same  regions;  chest, 
every  where  sonorous  on  percussion  ;  pulse,  very  little  quicker 
than  natural  ,  tongue,  clean  on  edges,  brown  in  the  centre  ; 
thirst  urgent  ;  anorexia  ;  abdomen,  voluminous,  and  obscure 
fluctuation  could  be  detected.  Diarrhoea  and  night  sweats 
the  last  fifteen  days. 


Chap.   2.]  DILATATION    OF    THE    BRONCHIA.  213 

(Infusion  of  rice  and  the  trilicum  repens  for  drink  ;  dias- 
cordium  ;  frictions  with  the  tincture  of  digitahs  ;  two  rice 
creams). 

Up  to  the  19th  of  November,  when  death  took  place,  he 
gradually  became  weaker  ;  the  dyspnoea  increased,  and  for 
the  last  six  days  the  expectoration  resembled  a  greenish- 
colored  pea  soup;  no  change  in  auscultation  on  the  right  side. 
On  the  7th,  a  mucous  râle,  mingled  with  a  gurgling  sound, 
was  heard  under  the  left  clavicle  ;  posteriorly  and  superiorly 
the  respiratory  murmur  was  very  strong,  as  well  as  the  reso- 
nance of  the  voice  ;  there  was  a  loud  sonorous  râle  throughout 
the  whole  chest  during  the  last  four  days  ;  the  pulse  became 
very  frequent. 

Complete  anorexia  ;  nausea,  succeeded  by  vomitings,  with 
a  dry  tongue.  On  the  10th,  copious  diarrhœa  came  on,  and 
from  fifteen  to  twenty  stools  were  passed  daily  until  death. 
Drowsiness  was  almost  constant  the  last  four  days,  and  he  ex- 
pired at  seven,  p.  m. 

Opening  of  the  corpse  thirty-seven  hours  after  death. 

Exterior.  —  Slight  œdema  of  the  lower  extremities. 

Head.  —  Close  adherence  of  dura  mater  to  sagittal  suture, 
slight  sub-arachnoidean  infiltration  ;  cortical  substance,  rather 
pink  ;  the  medullary  was  slightly  injected  and  of  good  con- 
sistence ;  a  spoonful  of  clear  fluid  in  each  lateral  ventricle  ; 
rather  less  in  the  inferior  occipital  fossae. 

Neck.  —  Epiglottis  and  larynx,  natural  ;  mucous  mem- 
brane of  the  trachea,  red  throughout,  especially  inferiorly, 
otherwise  perfectly  healthy. 

Chest.  —  Numerous  cellular  adhesions  over  the  whole  of 
both  lungs.  The  summit  of  the  right  lung,  to  the  extent  of 
two  inches,  seemed   formed   by   numerous   cysts,  varying  in 


■214  SYMPTOMS. DIAGNOSIS,    SECOND    PERIOD;    [Part  II, 

size  from  that  of  a  pea  to  a  large  nut.  These  apparent  cysts 
were  formed  by  dilated  bronchia,  containing  a  reddish  mucous 
fluid,  or  a  yellowish  opaque  substance  of  variable  consistence. 
They  were  closely  compacted  together,  and  formed  by  a  thin 
mucous  membrane,  resembling  that  of  the  colon,  rather  red, 
resisting,  and  continuous  with  that  of  the  bronchia,  which  ap- 
peared natural  in  every  other  part  of  their  extent.  Some  of 
them  had  a  kind  of  valves  to  them.  The  same  lesion  existed 
in  the  summit  of  the  left  lung,  but  occupied  but  an  inch  and  a 
half  merely,  and  the  dilatation  of  the  bronchia  was  less  consid- 
erable. There  were  neither  tubercles  nor  tuberculous  matter 
in  any  portion  of  the  lungs.  The  right  was  slightly  congested, 
but  not  so  supple  as  the  right,  and  with  the  exception  of  the 
dilatation  described,  healthy  ;  the  heart  was  small  ;  the  aorta 
presented  throughout  its  whole  length  some  prominent  yellow- 
ish spots. 

Abdomen.  —  About  three  quarts  of  clear  serous  fluid  in  the 
abdominal  cavity  ;  stomach,  small;  the  mucous  membrane,  of 
a  greyish  color  near  the  pylorus  ;  punctated  with  red  spots 
every  where  else  ;  in  some  points  it  was  thin  and  extremely 
soft,  except  in  its  greyish  part,  so  that  it  was  capable  of  being 
detached  in  fragments,  from  one  to  two  lines  long  only  ;  small 
intestine,  contracted,  of  twice  its  usual  thickness  and  very  short  ; 
its  lining  membrane  as  soft  as  mucus;  that  of  the  colon  was  a 
little  thickened  throughout,  extremely  softened  in  the  sigmoid 
flexure,  and  every  where  rather  less  firm  than  natural  ;  the  liver 
adhered  to  the  diaphragm  ;  structure,  healthy  ;  gall-bladder, 
not  larger  than  a  filbert  ;  it  contained  two  blackish,  soft,  nodu- 
lated concretions,  enveloped  in  mucus  ;  its  parietes  exceeded 
half  a  line  in  thickness,  principally  in  consequence  of  the  thick- 
ened state  of  the  mucous  membrane  ;  the  submucous  layer, 
was  much  indurated  ;  cystic  duct,  natural. 


Chap.   2.]  DILATATION    OF    THE    BRONCHIA.  215 

282.  When  we  first  saw  the  patient,  we  consideredhim 
laboring  under  some  organic  abdominal  affection  and  an  ex- 
tremely chronic  phthisis,  which  liad  only  caused  very  limited 
disorganization.  The  clearness  of  percussion  under  the  clavi- 
cles at  first  inspired  us  with  doubts;  but  auscultation  indicating 
the  existence  of  an  excavation  in  the  same  point,  we  could  not 
avoid  supposing  it  the  result  of  suppurated  tubercles;  a  sup- 
position apparently  confirmed  by  the  cough,  dyspnoea,  expec- 
toration, and  more  especially  by  the  part  of  the  chest  in  which 
the  excavation  was  situated.  We  were  mistaken  in  our  con- 
jectures, and  perhaps  should  be  again  so,  were  a  similar  fact 
to  be  presented  to  us.*  However,  let  us  remark,  that  there 
were  neither  haemoptysis,  pains  in  the  chest,  nor  striated  ex- 
pectoration ;  from  all  which  we  may  conclude,  that  the  exist- 
ence OÎ pectoriloquy  in  a  very  limited  space,  in  an  individual 
affected  with  chronic  bronchitis,  and  when  the  expectoration 
is  opaque,  greenish,  purulent,  and  rounded,  is  not  sufficient  to 
determine  the  existence  of  tubercles  ;  to  do  this  with  certainty, 
either  haemoptysis,  pains  in  the  chest,  or  dicninished  sound  on 
percussion  round  the  excavation,  must  be  present  at  the  same 
time  with  those  just  mentioned. 

*  James  Jackson,  Jr.,  in  a  letter  to  his  father,  dated  January  25th,  1833, 
mentions  the  case  "of  a  young  girl  with  whom  we  made  acquaintance  last 
year  at  La  Pitié.  She  then  entered  Louis's  wards  in  March;  cough,  ex- 
cessive ;  oppression  ;  respiration,  at  last  up  to  sixty-six  in  a  minute;  exces- 
sive subcrepitous  rale,  the  longest  and  most  numerous  1  ever  heard,  over  the 
whole  right  lung  behind,  and  all  this  of  recent  origin.  Louis  doubted  be- 
tween bronchitis  and  acute  phthisis.  Tbe  actual  symptoms  could  not  be 
explained  by  either,  but  the  excessive  dyspnœa  led  him  to  hold  the  last  in 
suspicion."  The  cholera  came,  and  the  patient  passed  from  the  ward.  At 
the  date  of  the  letter  she  came  again,  ill  with  the  small-pox.  She  died, 
and  a  very  great  dilatation  of  the  bronchia  was  found,  with  some  gangre- 
nous spots  in  the  substance  of  the  lungs.  See  Jackson's  Memoir,  page  167. 
—  H.  LB. 


216        sr.MPTOMs.  —  DIAGNOSIS,  SECOND  PERIOD.   [Part  II, 

283.  No  doubt  similar  facts  are  rare  ;  and  indeed  years 
may  elapse  without  encountering  a  second  ;  but  we  must  not, 
on  that  account,  neglect  it,  since  it  is  a  striking  proof  of  the 
difficulty  of  diagnosis  in  circumstances  apparently  the  most 
favorable,  and  of  the  importance  of  some  local  symptoms, 
especially  of  percussion.  It  was  in  fact  more  than  probable, 
as  we  at  first  suspected,  that  a  tuberculous  affection  of  ten 
years  duration  would  have  terminated  in  some  induration  of 
the  lung,  and  produced  corresponding  results  from  percussion.* 

284.  Pectoriloquy  did  not  always  exist  opposite  excavations, 
even  when  there  was  free  communication  with  the  larger  bron- 
chia, and  they  were  of  considerable  size.  Occasionally  also  the 
resonance  of  the  voice  was  not  very  distinct,  but  usually,  at 
the  same  time,  there  were  gurgling  and  tracheal  respiration  ; 
so  that  when  these  two  symptoms  are  present,  particularly  if 
beneath  the  clavicles,  where  great  tuberculous  cavities  are 
found,  they  are  equivalent  in  value  to' pectoriloquy,  and  like 
it  show  the  existence  of  a  cavity. 

285.  To  the  preceding  symptoms  were  conjoined  in  some 
cases  metallic  tinkling.  This  peculiar  sound,  which  we  have 
heard  in  three  instances  (Obs.  1),  announces,  as  M.  Laennee 
has  said,  a  large  tuberculous  excavation,  filled  with  air  and 
fluid,  and  communicating  with  the  bronchia.  It  also  exists 
after  perforation  of  the  lung  by  the  emptying  of  a  softened 
tubercle  into  the  pleural  cavity  (424,  Stc)  ;  but  the  distinc- 
tion between  these  two  cases  is  easy  ;  for,  when  the  sound 
occurs  in  a  tuberculous  excavation,  it  is  associated  with  pec- 
toriloquy and   tracheal  respiration,  both  of  which   are  absent 

*  Wc  are  aware  of  the  truth  of  M.  Laennec's  observation,  that  induration 
round  tuberculous  cavities  does  not  always  prevent  the  chest  from  being 
sonorous  ;  but  for  this  to  be  the  case  the  excavation  must  be  very  extensive 
(Obs,  1,28).  — Louis. 


Chap.  3.]  PNEUMONIA    AND     PLEURISY,     &;c.  217 

when  this  is  not  the  case.  We  shall  not  insist  on  the  geiieral 
symptoms,  which  are  never  sufficient  for  the  diagnosis  of  local 
disease,  but  we  shall  observe  that  those  which  indicate  ulcer- 
ations of  the  epiglottis  and  larynx*  are  not  without  value; 
since,  from  our  researches  in  the  first  part  of  this  work  (60), 
these  lesions  appear  peculiar  to  phthisis.f 


CHAPTER    III. 


PNEUMONIA  AND  PLEURISY  OCCURRING  SHORTLY  BEFORE 

DEATH. 

286.  When  pneumonia  was  very  limited,  no  symptom  in- 
dicated its  existence  ;  but  when  more  extensive,  five  eighths 
of  the  patients  complained  of  pain  in  one  side  of  the  chest, 
three,  four,  or  five  days  before  death  :  at  the  same  time  the 
respiratory  murmur  was  weak,  mingled  with  a  fine  crepitation, 
and  percussion  was  more  or  less  dull  in  the  corresponding 
point.  The  expectoration  became  sometimes  viscous,  without, 
however,  presenting  any  other  of  the  characters  presented  by 

*  Mr.  Bedingfield  remarks,  in  his  valuable  Compendium  of  Medical 
Practice,  that  every  case  of  ulcerated  larynx  and  trachea  which  had  fallen 
under  his  observation  terminated  fatally;  and,  with  the  exception  of  two 
instances,  depending  upon  syphilis,  Di-.  Armstrong  was  equally  unsuccess- 
ful. These  results  are  confirmative  of  the  author's  conclusion  as  to  the 
dépendance  of  this  lesion  on  the  tubercles  in  the  lungs.  —  Cowan. 

t  For  some  remarks  in  relation  to  diagnosis,  see  Translator's  Appendix,  B. 
—  H.  I.  B. 

D   2 


218      SYMPTOMS.  PNEUMONIA  AND   PLEUKISY,  &£C.     [Part  II, 

pneumonia  when  it  occuis  in  subjects  not  weakened  by  pre- 
vious disease.  When  under  other  circumstances,  these  symp- 
toms are,  however,  sufficient  to  define  the  nature  of  the  com- 
plication, and  the  time  of  its  invasion  ;  they  also  prove  that 
pneumonia  may  happen  in  phthisical  patients  when  emaciation 
is  extreme,  and  that  the  existence  of  complications  with  great 
debility  is  not  an  insuperable  obstacle  to  the  diagnosis  of  ac- 
cidental intercurrent  diseases. 

237.  Pleurisy,  developed  under  the  same  circumstances, 
also  gives  rise  to  symptoms  by  which  it  may  be  detected  in 
the  majority  of  the  cases.  Seven  out  of  eleven  patients  were 
examples  of  this  complication,  and  they  had  all  experienced 
exacerbation  of  the  dyspnœa,  acute  pains  in  one  side  of  the 
thorax,  three,  nine,  eleven,  or  seventeen  days  before  death. 
In  three  among  these  there  was  an  increase  of  heat  and  thirst, 
and  the  pulse  was  accelerated.  Œgophony  was  present  in 
two,  and  would  no  doubt  have  been  more  frequently  de- 
tected, had  complete  examination  been  possible.  In  cases  of 
extreme  weakness,  the  necessary  exertion  to  effect  this  might 
not  be  free  from  danger.  The  symptoms,  however,  were  suffi- 
ciently marked  to  enable  us  to  form  a  diagnosis,  and  to  prove 
that  the  affection  existed  only  a  few  days  before  death. 

2S8.  If  pneumonia,  coming  on  in  the  last  period  of  phthisis, 
is  rapid  in  its  progress  and  accelerates  the  fatal  termination? 
this  is  not  the  case  in  an  earlier  stage  of  the  complaint,  for 
then  the  patients  are  enabled  to  continue  their  avocations, 
the  debility  and  emaciation  having  made  but  little  progress. 
Pneumonia  is  then,  in  fact,  almost  invariably  curable,  though 
associated  with  tuberculous  excavations.*  We  cannot  arrive 
at  the  same  conclusion  for   pleurisy,   when  coming  on  in-  the 

*  M.  Andral  makes  the  same  remark.  —  Louis. 


Chap.  4.]       ULCERATION    OF    THE    EPIGLOTTIS.  219 

course  of  phthisis  ;  for,  with  one  exception,  we  have  never 
seen  it  entirely  cured,  not  even  when  occurring  before  tuber- 
culous softening  had  taken  place.  The  symptoms  might  often 
he  palliated ,  the  effusion  in  part  dissipated,  but  it  was  never 
wholly  absorbed,  and  after  a  variable  period  of  time,  the  pa- 
tients died,  having  in  addition  to  the  tubercles  in  the  lungs, 
false  membranes  and  effusion  in  one  or  both  sides  of  the  chest. 


CHAPTER   IV. 


SYMPTOMS  OF  ULCERATIONS  OF  THE  EPIGLOTTIS,  LARYNX, 
AND  TRACHEA. 


ARTICLE     I. 

SYMPTOMS  OF  ULCERATIONS  OF  THE  EPIGLOTTIS. 

289.  Out  of  eighteen  patients  in  whom  we  have  observed 
this  alteration,  in  six  there  were  no  ulcerations  either  of  the 
larynx  or  trachea.  Four  among  them  complained  of  a  varia- 
bly intense  pain  in  the  upper  part  of  the  thyroid  cartilage,  or 
between  this  and  the  os  hyoïdes.  The  pain  was  compared  to 
that  of  a  raw  sore,  to  prickings,  or  to  a  sense  of  burning.  It 
was  present  a  month,  two  months,  or  only  a  few  days  before 
death.  In  three  instances  there  was  dysphagia,  although  no 
alteration  existed  in  the  pharynx  or  tonsils  ;  liquids  were  some- 
times returned  by  the  nose.  Out  of  twelve  other  patients 
who  had  ulcerations  in   the  epiglottis,   larynx  and  trachea,  in 


220  sYMPTOBis.  —  EPIGLOTTIS  ;  [Part  II, 

four,  deglutition  was  difficult,  and  pain  was  complained  of  in 
the  same  region.  Only  one  among  them,  during  a  certain 
time,  rejected  liquids  by  the  nose. 

290.  Thus  the  sympton)s  of  ulceration  of  the  epiglottis 
become  evident  from  a  detail  of  the  facts,  viz.,  a  fixed  pain  in 
the  upper  portion  of  or  immediately  above  the  thyroid  carti- 
lage, with  some  difficulty  in  swallowing  and  the  return  of 
liquids  by  the  nose,  while  the  pharynx  and  tonsils  remain 
healthy.  These  symptoms  are  confirmed  by  what  we  observe 
in  ulcerations  of  the  larynx,  for  in  this  case  there  is  neither 
return  of  liquids  by  the  nose  nor  difficulty  in  deglutition,  so 
long  as  the  pharynx  and  epiglottis  are  not  affected.  Perhaps 
in  the  absence  of  the  symptoms  peculiar  to  ulceration  of  the 
larynx,  a  fixed  pain  at  tlie  upper  part  of  the  thyroid  cartilage 
would  sufficiently  indicate  those  of  the  epiglottis.  At  least 
this  would  appear  to  be  the  case  from  the  following  observa- 
tion, where  pain  was  almost  the  only  symptom  observed. 


TWELFTH     OBSERVATION. 

A  TAILOR,  set.  40,  of  a  weak  constitution,  born  of  parents 
who  died  at  an  advanced  age,  entered  the  hospital  of  La 
Charité,  October  l8th,  1824.  He  had  never  been  seriously 
ill,  and  was  not  liable  to  colds  ;  said  his  present  indisposition 
had  lasted  fifteen  months,  and  that  he  had  coughed  from  the 
commencement  ;  had  not  expectorated  during  the  first  two 
months,  after  which  the  expectoration  was  more  or  less  abund- 
ant and  soon  accompanied  with  dyspnoea.  Some  acute  pains 
were  felt  in  one  side  of  the  chest,  three  months  subsequently 
to  the  first  symptoms  ;  they  continued  fifteen  days,  recurring 


Chap.  4.]  ULCERATIONS.  221 

afterwards  at  two  different  periods,  but  of  a  little  shorter  dura- 
tion. For  the  last  fortnight  there  had  been  slight  soreness  of 
throat,  hoarseness  and  dysphagia  ;  had  had  occasional  perspi- 
rations, but  no  rigors  ;  the  appetite  had  gradually  diminished. 
The  diarrhoea  had  been  almost  constant  the  last  six  months, 
with  occasional  colic  ;  it  was  less  violent  after  the  first  two 
months.  The  emaciation  and  weakness  dated  from  the  com- 
mencement of  the  expectoration.  He  had  relinquished  his 
occupations  for  six  months,  and  been  confined  to  the  bed  the 
last  two. 

October  19th.  Face,  pale  and  thin  ;  pain  and  pricking  sen- 
sation at  the  upper  part  of  the  thyroid  cartilage  ;  sense  of  dry- 
ness in  the  same  region  ;  slight  difficulty  in  deglutition,  though 
the  pharynx  and  amygdala  were  natural  ;  no  peculiar  feeling 
in  the  course  of  the  trachea  ;  cough,  pretty  frequent  ;  expec- 
toration, not  copious  nor  quite  opaque  ;  slight  dulness  of  sound 
under  both  clavicles,  particularly  under  the  right,  w'here  it  occu- 
pied almost  the  whole  of  the  space  corresponding  to  the  upper 
lobe.  Tracheal  respiration  and  resonance  of  the  voice,  with- 
out pectoriloquy,  under  both  clavicles,  but  more  evident  under 
the  right  than  left.  Pulse,  ninety  ;  great  sensibility  to  cold. 
Appetite,  much  diminished;  little  thirst;  epigastrium,  not 
painful  ;  six  liquid  stools  with  very  slight  pain  the  last  twenty- 
four  hours. 

(Infusion  of  rice  with  quince  syrup  ;  diascordium  with  gr.  j. 
of  opium  three  times  a  day). 

On  the  following  days  the  expectoration  became  opaque 
and  of  a  dirty  color,  the  pain  of  the  throat  continued  almost  in 
the  same  degree,  and  the  appetite  quite  failed. 

November  7th.  Considerable  increase  of  diarrhœa  ;  tongue, 
natural  ;  pain  in  the  thyroid  cartilage  as  before  ;  deglutition  of 
saliva,   very  difficult  ;  no   alteration  of  voice  ;    no  uneasiness 


222  SYMPTOMS.  —  EPIGLOTTIS  ;  [Part  II, 

in  the  course  of  the  trachea  complained  of;  slight  acceleration 
of  the  pulse.  No  change  took  place  the  two  following  days. 
On-the  10th  of  November,  at  five,  a.  m.,  loss  of  consciousness, 
and  at  the  visit  we  found  him  lying  on  the  right  side,  the 
pupils  much  contracted,  the  eyelids  half  closed,  breatliing 
accelerated,  pulse  slow,  all  the  niovements  extremely  feeble, 
and  excited  only  by  the  changes  in  his  position  made  by  another 
person,  and  complete  insensibility.  No  change  occurred  be- 
fore death,  which  took  place  at  twelve,  m. 

Opening  of  the  corpse  twenty-tivo  hours  after  death. 

Exterior.  —  Extreme  emaciation.  Nothing  else  remark- 
able. 

Head.  —  Three  small  spoonsful  of  reddish,  slightly  turbid 
fluid  on  the  upper  surface  of  the  arachnoid.  Some  spots  of 
blood  on  the  inner  surface  of  the  dura  mater,  easily  removed, 
and  not  adherent  by  false  membranes.  A  tolerable  consistent 
infiltration  beneath  the  arachnoid.  Haifa  spoonful  of  fluid  in 
each  lateral  ventricle,  rather  more  in  the  inferior  occipital 
fossae.     Brain,  slightly  softened  and  injected. 

Neck.  —  Œdema  of  the  glottis,  of  a  line  and  a  half  thick 
near  the  arytsenoid  cartilages,  much  less  elsewhere.  Mucous 
membrane  of  the  epiglottis,  more  or  less  red,  presenting  some 
ulcerations  on  its  lingual  surface  ;  it  was  of  the  same  color,  with 
an  unusually  shining  appearance,  and  also  accompanied  with 
ulcerations  on  its  laryngeal  surface.  The  fibro-cartilage  was 
denuded  at  the  bottom  of  one  of  these,  and  superiorly  on  the 
right  side  it  was  completely  destroyed  to  the  extent  of  two 
lines.  Larynx,  natural  ;  mucous  membrane  of  the  trachea, 
red  inferiorly. 

TnoRAX.  —  The  left  lung  presented  some  cellular  adhe- 
sions superiorly  and  posteriorly.     The  right  was  universally 


Chap.  4.]  ULCERATIONS.  223 

adherent,  and  at  its  upper  portion  the  false  membrane  was 
semi-cartilaginous  ;  in  other  parts  it  was  moderately  dense 
cellular  membrane.  In  the  summit  of  the  upper  lobe  there 
was  a  vast  anfractuous  excavation,  as  large  as  the  patient's 
closed  hand.  It  was  almost  filled  by  a  red  and  turbid 
fluid,  traversed  by  thin,  cord-like  prolongations,  and  partially 
lined  by  fragments  of  a  soft  false  membrane.  Its  parietes 
were  scarcely  two  lines  thick  posteriorly  ;  they  were  thicker 
anteriorly,  and  were  formed  by  a  dark  greyish  substance,  more 
or  less  firm,  and  in  many  points  semi-transparent.  The  re- 
mainder of  the  lobe  was  dense,  converted  into  the  grey,  semi- 
transparent  matter,  into  tubercles,  or  into  partially  filled  cavi- 
ties. There  were  also  in  the  upper  part  of  the  two  other 
lobes  some  unsoftened  tubercles,  and  the  grey,  semi-transpa- 
rent substance.  The  same  lesions  existed  in  the  left  lung,  but 
were  less  extensive.  The. contents  of  the  right  bronchia  were 
red  and  analogous  to  those  of  the  large  excavation.  The 
mucous  membrane  was  redder  at  the  summit  than  at  the  base 
of  the  lung.  The  heart  was  small  ;  the  aorta  presented 
throughout  its  whole  extent  numerous  yellow-colored  patches. 
Abdomen.  — Two  quarts  of  clear  serosity  in  the  peritoneal 
cavity.  Stomach,  contracted,  enclosing  a  large  quantity  of 
very  viscid  mucus.  Its  lining  membrane  formed  numerous 
folds,  was  every  where  rather  red,  and  of  normal  consistence 
and  thickness.  The  small  intestine  was  extremely  contracted, 
allowing  the  entérotome*  to  pass  with  difficulty,  and  contain- 
ed much  grey-colored  mucus.  Its  mucous  niembrane  was 
sound,  with  the  exception  of  some  small  tuberculous  granula- 
tions, ulcerated  or  entire,  which  existed  in  the  lower  fourth, 


*  A  peculiarly  formed  pair  of  scissors   for  opening  the  alimentaiy  canal. 
H.  I.  B. 


224  SYMPTOMS.  —  epiglottis;  [Part  II, 

either  on  the  glandular  patches  or  in  their  intervals.  The 
large  intestine  was  filled  with  a  turbid,  greyish-colored,  offen- 
sive fluid.  From  the  cascal  valve  downwards,  its  muscular 
coat  was  denuded  for  a  foot  and  a  half,  with  the  exception  of 
a  belt  of  sound  mucous  membrane  of  about  an  inch  in  breadth, 
corresponding  to  which  the  parietes  of  the  intestine  were 
healthy.  Thus  denuded,  it  was  greyish-colored,  firm,  about 
a  line  thick,  with  here  and  there  fragments  of  raucous  mem- 
brane and  cellular  tissue  on  the  point  of  being  detached. 
Lower  down  there  were  four  ulcerations  of  an  inch  and  a  half 
in  diameter,  where  the  exposed  muscular  layer  was  half  aline 
thick.  The  mucous  membrane  was  very  pale  and  exceed- 
ingly soft  in  the  sigmoid  flexure  and  rectum.  The  right  meso- 
colic  glands  were  rounded,  of  the  size  of  a  large  pea,  greyish- 
colored,  shining,  opaque,  but  not  tuberculated  ;  those  of  the 
mesentery  were  natural  ;  liver,  of  ordinary  volume,  firmer 
than  usual  ;  gall-bladder,  greatly  distended  by  a  clear  reddish 
colored  bile.     The  other  viscera  were  healthy. 

291.  We  shall  not  extend  our  reflections  on  this  observa- 
tion, where  so  marked  a  correspondence  existed  between  the 
symptoms  and  the  morbid  changes  observed  after  death.  The 
ulcerations  of  the  epiglottis  exactly  coincided  with  the  spot 
where  the  patient  complained  of  pain,  and  also  explained  the 
slight  difficulty  in  swallowing.  The  tracheal  respiration  and 
the  resonance  of  the  voice  were  in  proportion  to  the  extent  of 
the  excavations.  The  absence  of  sonorousness  on  percussion 
announced  the  presence  of  much  grey  and  tuberculous  matter 
in  the  part.  The  lesions  of  the  large  intestine  could  scarcely 
be  more  extensive  after  long  and  copious  diarrhœa.  Lastly, 
if  the  gastric  mucous  membrane  was  perfectly  sound,  with  the 
exception  of  being  slightly  red,  (the  effect  probably  of  some 


Chap.  4.]  ULCERATIONS    AND    DESTRUCTION.  225 

recent  lesion),  the  patient  had  never  had  either  nausea,  vomit- 
ing, or  epigastric  pains. 

Let  us  observe  that  this  is  the  only  instance  in  phthisical 
patients,  where  we  have  found  ulcerations  on  the  lingual  sur- 
face of  the  epiglottis,  and  where  the  lymphatic  glands  of  one 
of  the  mesocolons  were  transformed  into  cancerous  matter. 
We  have  already  made  the  same  remark  in  relation  to  the 
mesenteric  glands  (Obs.  4). 

292.  The  following  case  is  an  example  o^  the  complete 
destruction  of  the  epiglottis,  and  confirms  what  has  been  said 
respecting  the  peculiar  symptoms  attending  the  ulcerations  of 
this  organ. 


THIRTEENTPI     OBSERVATION. 

A  GARDENER,  Set.  33,  tall,  of  a  lymphatic  and  sanguineous 
temperament,  of  a  strong  constitution  and  very  well  made,  en- 
tered the  hospital  of  La  Charité,  September  6th,  1824.  Five 
years  previously  he  was  attacked  with  pneumonia,  and  after 
convalescence  his  breathing  was  not  at  all  affected  ;  long  be- 
fore this  he  was  subject  to  hoarseness  coming  on  in  the  winter  ; 
he  said  that  he  had  been  now  ill  a  year,  and  had  ceased  his  oc- 
cupations six  weeks.  At  the  commencement,  he  was  attacked 
with  cough,  irregular  rigors,  and  expectorated  a  fluid  like 
frothy  saliva.  The  cough  had  since  continued;  the  expecto- 
ration had  become  rather  less  clear  and  more  copious  the  last 
four  months  ;  he  had  been  always  very  sensible  to  cold,  a 
slight  decrease  of  temperature  occasioning  shiverings  ;  for  six 
months  night  perspirations  had  been  constant,  witii  increased 
heat  of  surface.  The  voice  had  become  affected  during  the 
E   2 


226  SYMPTOMS.  —  EPIGLOTTIS  ;  [Pait  lly 

last  three  months,  and  the  upper  part  of  the  larynx  was  the 
seat  of  more  or  less  acute  pain  ;  liquids  were  returned  by  the 
nose  during  the  last  five  weeks.  Diminution  of  appetite  from 
the  first  ;  of  late  the  digestion  had  becocne  languid,  and  there 
was  occasional  vomiting  with  the  cough.  No  uneasy  sensa- 
tion in  the  epigastrium,  no  pain  of  side,  no  hemoptysis  ;  grad- 
ual emaciation  the  last  three  months. 

September  7th.  Face,  rather  pale  ;  weakness,  not  extreme  y 
sleep,  interrupted  by  cough  ;  hoarseness,  with  great  inequality 
and  discordance  of  voice.  A  constant  lancinating  pain  be- 
tween the  thyroid  cartilage  and  os  hyoides,  accompanied  with 
sense  of  heat  and  dryness  ;  the  pain  was  increased  by  cough,, 
by  speaking,  by  flexion  of  neck  forwards,  and  by  deglutition  ; 
the  latter  was  frequently  difficult,  and  provoked  the  rejection 
of  liquids  through  the  nose.  Cough,  frequent  ;  dyspnœa, 
urgent  during  the  night;  some  scanty,  opaque,  yellowish  and 
and  o-reenish  sputa  floating  on  the  surface  of  a  copious,  clear 
fluid,  or  sunk  at  the  bottom.  Percussion,  on  both  sides  an- 
teriorly, clear  ;  pressure  under  the  left  clavicle  was  painful, 
and  the  exj)iration  tracheal  ',  under  the  right  the  respiratory 
murmur  was  rather  stronger  than  natural  ;  there  was  great 
resonance  of  voice  and  bronchial  respiration  between  the  clavi- 
cles. Pulse,  moderately  accelerated  ;  heat,  natural  ;  tongue 
and  pharynx  presented  no  alteration  ;  epigastrium,  not  painful. 
In  the  evening  the  patient  passed  one  stool  of  good  consist- 
ence, and  only  complained  of  the  pain  in  his  throat. 

(Looch  ;    gum  mixture  ;  two  rice  creams). 

Some  slight  amendment  the  following  days,  and  on  the  17th 
he  was  only  sensible  of  the  pain  in  the  neck  when  cough- 
ing, speaking,  or  swallowing  ;  nothing  remarkable  in  the  ex- 
pectoration ;  respiration  was  tracheal,  and  there  was  pectoril- 
oquy under  the  right  clavicle,  and  posteriorly  in  the  corres- 


Chap.  4.]         ULCERATIONS    AND    DESTRUCTION.  227 

ponding  point;  little  appetite;  stools,  liquid  or  pulpy,  and 
not  numerous. 

October  4th.  Increase  of  pain,  constant  ;  deglutition,  espe- 
cially of  solids,  very  difficult  ;  liquids  did  not  return  by  the 
nose  ;  increased  appetite  ;  this  state  continued  for  some  days, 
and  the  other  symptoms  increased.  On  the  12th,  liquids  alone 
could  be  swallowed;  the  pharynx  and  tonsils  were,  as  before, 
unaffected  ;  the  expectoration  presented  the  same  characters, 
and  seemed  occasionally  to  be  detached  immediately  from  the 
larynx  ;  no  change  in  auscultation  ;  pulse,  rather  quick  ;  night 
perspirations,  copious  ;  alvine  evacuations,  daily,  of  natural 
consistence. 

(Twelve  leeches  to  neck). 

The  pain  persisted  ;  some  slight  decrease  of  the  burning 
sensation  in  the  larynx  ;  aphonia,  constant  ;  the  expectora- 
tion was  thick  and  greenish  ;  diarrhœa  came  on  and  contin- 
ued uninterruptedly  from  the  15th  to  the  31st,  when  death 
took  place.  The  appetite  had  suddenly  ceased,  the  epigas- 
trium had  become  painful  on  pressure,  and  pulsating  pains 
were  complained  of  in  the  same  region  ;  the  tongue  was 
always  natural. 

Opening  of  the  corpse  tiventy-nine  hours  after  death. 

Exterior.  —  Emaciation,  almost  extreme. 

Head.  —  The  dura  mater  presented  on  both  sides  some 
lacerations  through  which  the  arachnoidean  granulations  were 
apparent  ;  pia  mater,  injected,  easily  torn  ;  cerebral  substance, 
normal.  There  was  a  spoonful  of  clear  fluid  in  each  of  the 
lateral  ventricles. 

Neck. — The  base  of  the  tongue  and  lower  part  of  the 
pharynx  presented  many  small,  and,  in  general,  scattered  ulcer- 
ations, but  they  were  numerous,  and  clustered  together  in  one 


228  SYMPTOMS.  —  epiglottis;  [Part  11, 

point  only.  The  epiglottis,  the  lateral  ligaments  and  superior 
vocal  cords  were  completely  destroyed  ;  the  lower  were  only 
partially  so.  Nearly  the  whole  of  the  surface,  where  this  de- 
struction took  place,  was  more  or  less  red,  indurated  and  of 
an  uneven  aspect  ;  the  arytaenoid  cartilages  were  sound,  with 
their  articular  surface  exposed.  The  mucous  membrane  of 
the  trachea  was  of  a  light  pink  tinge,  but  its  color  and  consist- 
ence were  healthy. 

Thorax.  —  On  opening  the  chest  the  lungs  did  not  col- 
lapse, and  the  pulmonary  vescicles  were  generally  dilated  ; 
the  right  lung  was  every  where  adherent  ;  the  left,  which  was 
entirely  free,  presented  on  its  upper  lobe  a  kind  of  wrinkled 
surface,  corresponding  to  a  small,  very  indurated  mass  of  grey, 
semi-transparent  substance,  situated  about  half  an  inch  be- 
neath the  pleura,  and  giving  off  some  small  prolongations  of 
the  same  nature.  Near  it  was  a  middle  sized  tuberculous  ex- 
cavation, lined  by  a  false  membrane,  and  some  fragments  of 
iiepatized  lung.  There  were  also  numerous  grey,  semi-transpa- 
rent granulations,  diminishing  both  in  number  and  volume  from 
above  downwards.  The  right  lung  offered  in  its  upper  lobe  a 
pretty  large  excavation,  communicating  with  one  in  the  lower 
lobe.  Both  contained  a  red,  thick,  opaque  fluid,  and  were 
lined  by  a  firm,  grey-colored,  serai-transparent  false  membrane. 
There  were  also  numerous  softened  tubercles  and  grey  granu- 
lations in  the  upper  lobe;  these  last  were  likewise  numerous 
in  the  lower;  heart  and  aorta,  natural. 

Abdomen.  —  Stomach,  voluminous  ;  its  mucous  membrane 
rather  red  in  the  great  cul-de-sac,  grey-colored  and  mamillated 
in  the  rest  of  its  extent  with  the  exception  of  a  limited  por- 
tion of  the  posterior  surface  near  the  small  curve  ;  it  was 
rather  firmer  than  natural  in  the  part  corresponding  to  the 
grey  color;  the  last  twelve  patches  of  the  small  intestine  pre- 


Chap.  4.]         ULCERATIONS    AND    DESTRUCTION.  229 

sented  some  ulcerations,  and  a  few  semi-cartilaginous  granu- 
lations. The  remainder  of  the  lining  membrane  was  healthy  ; 
that  of  the  large  intestine  was  thick  and  softened,  but  might 
still  be  detached  in  fragments  of  one  or  two  lines  in  length  ;  it 
was  not  ulcerated.  The  liver  was  voluminous  and  soft  ;  the 
bile  of  the  gall-bladder,  a  little  thicker  than  natural  ;  spleen, 
small,  and  easily  broken  down  ;  no  other  alteration. 

293.  Jn  this,  as  in  the  preceding  observation,  there  were 
pains  in  the  upper  part  of  the  thyroid  cartilage,  or  between  it 
and  the  OS  hyoides,  with  difficult  deglutition.  But  both  of  the 
symptoms  in  the  present  instance  were  much  more  intense, 
absorbed  the  attention  of  the  patient,  and  corresponded  to  the 
extensive  nature  of  the  alteration.  The  pain  was  constant, 
lancinating,  accompanied  with  a  sense  of  heat,  increased  by 
all  the  movements  of  the  neck,  and  especially  by  swallowing, 
which  became  daily  more  difficult  ;  for  a  long  time  a  part  of 
the  liquid  he  had  to  swallow  was  returned  by  the  nose.  The 
deglutition  of  solid  food  was  always  more  difficult  than  that  of 
fluids,  and  quite  impossible  during  the  last  fifteen  days.  The 
destruction  of  the  epiglottis  and  superior  vocal  cords  was  com- 
plete, while  it  was  only  partial  in  the  inferior.  The  dis- 
organization appears,  therefore,  to  have  proceeded  from  above 
downwards.  The  afiection  of  the  epiglottis  was  no  doubt  in 
the  commencement  without  complication  ;  aud  probably  the 
pain  and  dysphagia  were  at  first  exclusively  depending  upon 
it  ;  the  latter  probably  had  never  any  other  source. 

294.  The  progress  of  the  symptoms  was  slow  and  constant  ; 
and  as  we  do  not  know  whether  the  epiglottis  is  more  neces- 
sary for  the  deglutition  of  solids  than  fluids,*  we  cannot  decide 

*  M.  Magendie  relates  two  cases  of  complete  destruction  of  the  epiglottis, 
where  deglutition  was  not  at  all  impeded.     He  thinks  that,  when  dysphagia 


230  SYMFTOMS.  —  EPIGLOTTIS  ;  [Part  11, 

wliether  its  entire  destruction  took  place  during  the  last  fifteen 
days  only,  or  at  a  much  earlier  period.  The  patient  had 
never  labored  under  venereal  disease  ;  and  from  what  we 
have  before  stated,  especially  in  the  summary  of  the  first  part 
of  this  volume,  the  tendency  to  ulceration  in  phthisis  appears 
so  great  as  to  render  it  unnecessary  for  us  to  seek  for  any 
other  cause  in  the  present  case. 

295.  The  following  observation  is  another  very  remarkable 
example  of  the  symptoms  we  are  considering. 


FOURTEENTH    OBSERVATION. 

A  MANUFACTURER  of  artificial  flowers,  set.  18,  of  a  rather 
delicate  constitution,  entered  the  hospital  of  La  Charité, 
December  23d,  1824.  For  the  last  seventeen  months,  he 
was  convalescent  from  what  he  said  was  called  ascites,  but 
which  had  been  treated  in  the  commencement  by  the  appli- 
cation of  seventy-five  leeches  to  the  abdomen.  He  had  been 
confined  to  his  bed  a  year,  without  having  ever  experienced 
abdominal  pains,  fever,  or  even  marked  loss  of  appetite  ;  his 
strength  returned  very  slowly,  and  he  had  not  yet  completely 
regained  his  flesh.  Five  months  before  entering  the  hospital, 
he  was  attacked  with  slight  haemoptysis  during  five  successive 
days,  which  was  succeeded,  after  an  interval  of  seven  weeks, 
by  cough,  expectoration,  and  difficulty  of  breathing,  and  soon 

is  present,  it  is  to  be'attributcd  cither  to  caries  of  the  arytœnoid  cartilages,  or 
to  ulcerations  of  the  edges  of  the  glottis  preventing  this  opening  from  being 
accurately  closed  at  the  moment  of  deglutition.  Vide  Précis  élémen- 
taire de  Physiologie,  page  67.     Third  edition.  —  Cowan. 


Chap.  4.]    ULCERATIONS  AND  DESTRUCTION.  231 

after  by  perspirations  every  night  ;  no  loss  of  appetite  ;  stools^, 
regular;  he  had  ceased  his  usual  occupations  seven  days  be- 
fore we  saw  him. 

December  24th.  General  paleness  of  surface  ;  great  de- 
bility with  but  slight  emaciation  ;  breathing  a  little  oppressed; 
cough,  infrequent  ;  expectoration,  clear,  and  rather  viscous  ; 
percussion,  every  where  good,  except  for  about  two  inches 
under  the  left  clavicle,  where  the  sound  was  rather  dull  ;  in 
the  same  region  the  respiration  was  loud,  with  sonorous  râle, 
and  accompanied  with  slight  pain;  a  similar  râle,  though  more 
feeble,  existed  under  the  right  clavicle  ;  we  could  no  where 
detect  tracheal  respiration,  pectoriloquy  or  resonance  of  the 
voice  ;  the  pulse  was  somewhat  accelerated  ;,  heat  of  skin, 
moderate  ;  perspirations  copious  and  universal  during  the 
night,  not  preceded  by  rigors  ;  tongue,  pale  and  whitish  ;  ap- 
petite rather  less  than  when  in  health  ;  thirst,  natural  ;  stools, 
regular. 

(Pectoral  infusion  ;  gum  potion  ;  one  fourth  of  full  house 
allowance). 

January  1st.  An  acute  pain  complained  of  to  the  left  of  the 
OS  hyoides,  with  an  intense  burning  sensation,  which  was  in- 
creased by  cough,  external  pressure  and  deglutition  ;  the 
latter  was  accomplished  with  difficulty,  although  the  tonsils 
and  pharynx  were  natural  ;  the  next  day  the  dysphagia  was 
increased,  and  liquids  were  partially  ejected  by  the  nose. 
From  this  time  until  death,  a  period  of  three  months  and  a 
half,  these  symptom.s  continued  with  only  slight  variations; 
the  patient  could  only  drink  by  mouthfuls,  and  even  then  some 
drops  of  the  fluid  were  returned  by  the  nose  ;  the  swallowing 
of  solids  or  liquids  seemed  equally  painful,  and  the  increased 
suffering  caused  by  the  attempt  absorbed  the  patient's  atten- 
tion ;    he  seldom  complained  of  any   thing   else.     Leeches 


232  SYMPTOMS.  —  EPIGLOTTIS  ;  [Part  II, 

were  twice  applied  to  the  neck  (on  the  9th  and  11th  of  Jan- 
uary) without  any  success  ;  a  blister  applied  some  days  after- 
wards over  the  part  where  pain  was  complained  of,  proved 
equally  inefficacious. 

The  voice  became  slightly  altered  on  the  5th  of  January  ; 
on  the  25th,  the  aphonia  was  complete  and  continued  so  until 
death.  During  the  last  month  the  pain  in  the  os  hyoides  ex- 
tended to  the  inferior  portion  of  the  larynx. 

There  was  generally  considerable  oppression,  and  for  the  last 
two  months  the  breathing  was  hurried.  From  the  9th  of  Jan- 
uary there  were  some  nummulated  or  ragged  sputa,  surrounded 
by  a  fluid  rather  clear,  and  tolei-ably  abundant  ;  on  the  same 
day,  the  dulness  of  sound  occupied  a  greater  extent,  and  was 
more  evident  under  the  left  clavicle  than  at  the  time  of  the 
entrance  of  the  patient  into  the  hospital  ;  there  was  some 
crackling  in  the  same  region,  and  below  this  the  respiratory 
murmur  was  very  indistinct  ;  the  respiration  was  tracheal  un- 
der the  right  clavicle,  and  the  air  seemed  to  enter  the  stetho- 
scope when  the  patient  spoke.  February  13th.  This  two-fold 
phenomenon  existed  under  both  clavicles  ;  the  respiration  was 
feeble,  and  on  percussion  the  sound  under  the  left  clavicle 
was  rather  dull.  Towards  the  end  of  February  there  were 
some  striated  sputa.  On  the  4th  of  April  many  of  them  were 
of  a  pale  pink  color.  On  the  5th,  when  the  patient  was  alone 
in  the  garden,  a  slight  hcemoptysis  occurred,  which  ceased  very 
soon. 

January  9th.  Pulse,  eighty-five;  on  the  ITth,  it  was  one 
hundred.  It  was  subsequently  either  faster  or  slower.  Dur- 
ing the  last  two  months  the  heat  of  the  surfiice  was  increased, 
the  perspirations  were  universal  and  copious,  without  previous 
rigors. 

The  tongue  was  occasionally  whitish,  but  never  red  ;  appe- 


Chap.   4.]         ULCERATION    AND    DESTRUCTION.  233 

tite,  generally  good  ;  digestion,  easy  ;  the  patient  was  very 
ill-humored  when  put  upon  a  strict  diet;  diarrhoea  came 
on  about  the  middle  of  January,  was  almost  constant,  and  the 
stools  were  frequent  towards  the  end  of  February  and  in  the 
beginning  of  March  ;  some  nausea  occasionally  from  cough. 

The  loss  of  strength  was  rapid  ;  yet,  eight  days  before 
death,  the  patient  was  able  to  go  alone  into  the  garden.  He 
seldom  appeared  anxious  about  his  condition. 

On  the  evening  of  the  11th  of  April,  there  was  a  marked 
change  of  expression  ;  the  respiration  was  more  embarrassed  ; 
and  soon  afterwards  there  was  loss  of  consciousness,  which 
continued  until  five  o'clock  the  next  morning,  when  he  ex- 
pired. 

The  pectoral  infusion  had  been  replaced  by  rice  water  after 
the  diarrhœa  had  commenced;  diascordium,  either  with  or 
without  opium,  was  soon  added  to  it,  and  the  patient  took  it 
without  repugnance  ;  and  while  the  stools  continued  frequent  ; 
his  food  was  limited  to  some  rice  creams;  at  other  times  he 
had  a  fourth  or  one  eighth  of  the  usual  house  allowance. 

Opening  of  the  corpse  twenty-seven  hours  after  death. 

Exterior.  —  Extreme  emaciation.  Nothing  else  remark- 
able. 

Head.  —  Slight  sub-arachnoidean  infiltration  ;  a  few  mil- 
iary granulations,  adherent  to  the  arachnoid,  near  the  median 
fissure  ;  a  spoonful  of  fluid  in  each  lateral  ventricle  ;  brain, 
moderately  firm  ;  cortical  substance,  of  a  light  violet  color, 
especially  towards  the  base. 

Neck.  —  The  epiglottis  was  narrower  than  natural,  and 
about  one  line  thick  near  its  circumference  ;  the  mucous  mem- 
brane lining  its  inferior  surface  was  destroyed  ;  the  subjacent 
F  2 


234  SYMPTOMS. — EPIGLOTTIS  5  [Part  11, 

cellular  layer  thickened,  and  of  a  light  pink  color  ;  the  upper 
vocal  cords  deeply  ulcerated,  the  lower  only  superficially;  the 
arytaenoid  cartilages,  perfectly  sound  and  denuded  at  their 
base.  For  one  inch  below  the  vocal  cords,  the  lining  mem- 
brane of  the  trachea  was  of  a  pale  reddish  brown  color,  a  little 
thickened,  and  perforated  by  numerous  small  ulcerations. 
Near  the  bifurcation  it  was  redder,  and  presented  on  the  fleshy 
portion  two  ulcerations,  from  one  to  three  lines  in  diameter. 

Thorax.  —  The  lungs  were  every  where  adherent  at  their 
summit,  by  means  of  a  false  semi-cartilaginous  membrane,  from 
a  line  to  a  line  and  a  half  thick,  and  over  the  remainder  of 
their  surface  by  a  more  or  less  dense  cellular  tissue.  There 
was  a  very  rugged  excavation  in  the  summit  of  the  left  lung, 
as  laro^e  as  a  goose's  eva,  extending  to  the  interlobular  fissure, 
and  containing  a  red,  thick  and  turbid  fluid  ;  remnants  of 
tuberculous  matter  were  attached  to  its  inner  surface,  which 
was  not  invested  with  a  false  membrane.  Its  sides  were  thin 
posteriorly,  and  almost  entirely  formed  by  the  semi-cartilagi- 
nous false  membrane  we  have  already  described,  while  anteri- 
orly they  were  thick  and  indurated,  being  composed  of  a  large 
quantity  of  grey  and  blackish  substance,  more  or  less  semi- 
transparent,  which  was  interspersed  with  a  great  many  tuber- 
cles and  tuberculous  excavations,  and  occupied  almost  entirely 
the  remainder  of  the  lobe.  At  the  upper  part  of  the  inferior 
lobe  there  was  a  small  anfractuous  excavation,  containing  a 
similar  fluid  to  the  preceding,  and  some  grey  and  yellow- 
colored  granulations.  Analogous  lesions,  but  less  extensive, 
existed  on  the  right  side.  The  bronchial  mucous  membrane 
was  of  a  bright  red,  and  in  the  left  lung  offered  some  ulcera- 
tions.     Heart  and  aorta,  natural. 

Abdomen.  —  Short  and  dense  adhesions,  but  easily  broken, 
between  the  anterior  parietes,  omentum,  and  intestines.    Stom- 


Chap.  4.]         ULCERATIONS    AND    DESTRUCTION.  235 

ach,  of  moderate  dimensions  ;  mucous  membrane,  red  and  soft- 
ened in  a  part  of  the  great  cul-de-sac,  of  a  greyish  color  near  the 
pylorus,  white,  mamillated,  and  of  a  good  consistence  every 
where  else.  Near  the  great  curvature,  and  within  two  inches 
of  the  pylorus,  there  was  an  ulceration  of  six  lines  in  diameter, 
the  edges  of  which  were  everted  and  formed  by  the  softened 
and  red  mucous  membrane,  while  the  bottom  consisted  of  the 
cellular  layer,  whicli  was  uneven  and  twice  its  usual  thickness. 
Duodenum,  natural.  Small  intestine  contained  a  large  quan- 
tity of  mucus  in  its  superior  portions,  and  a  turbid,  greyish 
fluid  in  the  lower  ;  there  were  numerous  ulcerations  through- 
out its  whole  length,  but  which  were  largest  in  the  middle 
portion.  The  most  considerable  were  from  half  an  inch  to  an 
inch  in  surface  ;  the  majority  were  from  two  to  three  lines  in 
diameter,  situated  upon  the  patches,  dark-colored,  and  with 
flat  edges,  except  when  raised  by  tubercular  granulations. 
The  submucous  layer  was  slightly  thickened,  and  in  their  in- 
tervals the  raucous  membrane  was  softened.  Ulcerations 
existed  in  different  portions  of  the  great  intestine,  the  largest 
of  which  were  about  two  inches  in  surface,  situated  in  the 
course  of  the  caecum  and  ascending  colon.  Their  structure  was 
similar  to  what  we  have  described  in  the  small  intestine,  with 
the  exception  of  some  small  grey  granulations  in  their  centre, 
and  the  absence  of  tubercles  in  their  circumference.  Near 
the  anus  there  were  numerous  ulcerations,  about  the  size  of  a 
a  shilling,  or  rather  larger.  No  change  in  the  mesenteric  or 
mesocolic  glands  ;  liver,  rather  soft,  of  variable  color,  from  a 
yellowish  red  to  a  deep  red  ;  bile,  natural  ;  spleen  w^as  seven 
inches  long  by  five  in  breadth,  and  very  firm  ;  its  substance 
was  of  a  red  violet  color,  of  an  adipous  and  shining  aspect, 
and  distinctly  exhibiting  only  some  vascular  orifices,  with  a  kw 


236  SYMPTOMS.  —  EPIGLOTTIS.  [Part  II, 

white  attenuated  filaments.     The  other  viscera  of  the  abdo- 
men, healthy. 

296.  The  symptoms  pointed  out  as  pecuhar  to  ulcerations 
of  the  epiglottis,  viz.,  the  pain  above  the  thyroid  cartilage, 
the  difficulties  of  swallowing,  the  return  of  liquids  by  the  nose 
were  here  remarkably  prominent,  and  enabled  us  to  recognize 
the  nature  of  the  affection  soon  after  their  appearance.  Du- 
ring three  months  and  a  half  they  persisted  with  very  slight 
variations,  and,  as  in  the  preceding  example,  almost  entirely 
engrossed  the  patient's  attention.  The  change  of  voice  was 
soon  associated  with  the  earlier  symptoms,  so  that  the  affec- 
tion of  the  epiglottis  and  that  of  the  larynx  seem  to  have  origi- 
nated nearly  at  the  same  time. 

297.  In  regard  to  the  diagnosis  of  the  pulmonary  affection, 
we  may  observe,  that  at  the  period  of  the  patient's  admission 
into  the  hospital,  the  cough  only  dated  three  months  ;  there 
was  nothing  characteristic  in  the  expectoration  ;  there  was 
neither  resonance  of  the  voice  nor  pectoriloquy  ;  the  emaciation 
was  inconsiderable  ;  in  short,  the  general  symptoms  were  in- 
sufficient to  indicate  the  disease.  There  was,  however,  a  dull 
sound  under  one  of  the  clavicles,  or  in  that  region  where  tuber- 
cles are  first  deposited  ;  two  months  anteriorly  to  the  cough 
he  had  had  haemoptysis,  and  from  these  two  facts  we  did  not 
hesitate  to  consider  him  attacked  with  phthisis. 

298.  The  everted  state  of  the  edges  of  the  ulceration  in 
the  stomach  must  not  escape  notice  ;  it  is  the  only  instance 
of  the  kind  we  have  met.  In  analogous  cases  the  mucous 
membrane  was,  as  we  have  already  seen,  distinctly  ulcerated, 
and  preserved  round  the  edges  its  natural  connexion  with  the 
subjacent  layci-. 

The  patient  had  been  attacked,  two  years  and  a  half  before 


Chap.  4.]     LARYNX,  ULCERATIONS  ;    CHANGE   OF   VOICE.      237 

his  death,  with  a  disease  which  he  designated  as  abdominal 
dropsy  ;  but  the  universal  adhesions  of  the  peritoneum  proved 
it  to  be  peritonitis,  and  the  history  of  the  treatment  is  in  favor 
of  this  opinion. 


ARTICLE     II. 


SYMPTOMS  OF  ULCERATED  LARYNX. 


299.  These  vary  according  to  the  part  affected  and  the 
extent  and  depth  of  the  ulcerations.  Out  of  five  patients 
in  whom  they  were  confined  to  the  junction  of  the  vocal 
cords,  only  one  had  the  voice  affected,  and  this  from  the  six- 
tieth to  the  twentieth  day  preceding  death  ;  the  aphonia  after- 
wards became  complete,  and  there  were  occasional  pains  in 
the  larynx.  Four  others  complained  of  slight  dryness  and 
heat  in  the  throat  a  few  weeks  before  the  fatal  termination. 

In  nine  cases  where  the  ulcerations  were  small  and  super- 
ficial, situated  in  the  ventricles,  between  the  arytaenoid  carti- 
lages, or  the  inferior  chordae  vocales,  there  were  hoarseness  with 
more  or  less  alteration  of  the  voice,  sense  of  heat  and  prick- 
ings in  the  larynx,  and  subsequently  more  or  less  complete 
aphonia.  These  symptoms  were  slightly  pronounced,  and 
except  the  hoarseness  they  did  not  exist  in  two  of  the  pa- 
tients. In  three  this  symptom  commenced  eight  days,  and  in 
the  others  six  or  eight  months  before  death.  The  duration  of 
the  pain  was  equally  variable.  Complete  aphonia  existed 
only  in  two. 

In  the  eight  cases  where  the  ulcerations  of  the  larynx  were 
deep,  and  the  vocal  cords  more  or  less  completely  destroyed, 
similar  but  much  more  urgent  symptoms  were  observed. 
They  commenced  from  one  to  five  months  before  death.    The 


238  SYMPTOMS.  —  LARYNX.  [Part  II J 

hoarseness  preceded  the  pain  one  or  more  weeks,  and  occa- 
sionally several  months.  The  aphonia  was  present  twenty  or 
thirty  days,  two  months,  and  sometimes  at  a  still  earlier  pe- 
riod before  the  fatal  termination.  The  pain  (and  we  are 
only  speaking  of  cases  where  there  was  no  ulceration  of  the 
epiglottis)  was  occasionally  very  acute,  pungent,  lancinating, 
and  accompanied  with  a  sense  of  heat.  One  of  the  patients 
compared  it  to  the  sensation  of  a  raw  surface,  and  the  pres- 
ence of  some  streaks  of  blood  rather  frequently  in  the  ex- 
pectoration confirmed  the  comparison.  The  pain  was  exas- 
perated by  cough  and  speaking,  varied  in  intensity,  and  was 
sometimes  absent  for  a  few  days.  The  cough  in  this  class 
of  patients  had  also  a  peculiar  character;  it  was  discordant 
(déchirée)  or  wheezing  ;  the  deglutition  was  easy,  unless  there 
was  some  affection  of  the  epiglottis. 

300.  Thus,  whatever  modifications  existed  in  the  ulcera- 
tions of  the  larynx,  the  symptoms  were  always  of  the  same 
nature  ;  but  they  varied  much  in  intensity  and  duration. 
Hoarseness  was  present  in  four  fifths  of  the  cases.  Pain  was 
frequently  absent  when  the  ulcerations  were  superficial,  but  if 
these  were  deep  it  was  continued.  The  same  remark  applies 
to  the  aphonia  :  we  may,  therefore,  consider  as  symptoms  of 
superficial  ulcerations  of  the  larynx,  the  existence  of  a  slight 
pain  of  some  continuance  in  this  region,  conjoined  with  a 
greater  or  less  alteration  of  the  voice  ;  while,  on  the  other 
hand,  the  presence  of  an  acute,  continued,  and  often  violent 
pain,  followed  by  a  loss  of  voice  during  one  or  more  months, 
indicated  the  existence  of  deep  ulcerations.* 

*  We  have  not  thought  it  necessary  to  detail  any  individual  facts,  as  the 
ajccuiacy  of  our  description  may  be  deduced  from  those  which  are  scattered 
throughout  the  work.  —  Louis. 


Chap.  4.]  TRACHEA  ;  ulcerations.  239 


ARTICLE   III. 

SYMPTOMS  OF  ULCERATED  TRACHEA, 

301.  However  numerous  these  ulcerations  might  be,  they 
seldom  gave  rise  to  any  symptom.  Only  one  patient,  m 
whom  the  mucous  membrane  of  the  trachea  was  destroyed 
over  the  whole  of  its  muscular  portion,  complained  a  long 
while  before  death  of  a  sensation  of  some  obstruction  existing 
just  above  and  posterior  to  the  sternum,  which  was  soon  fol- 
lowed by  a  slight  sense  of  heat.  Some  individuals  complained 
of  pain  in  the  larynx,  although  this  was  not  ulcerated,  and  in 
the  trachea  the  largest  ulcerations  were  situated  near  the  bifur- 
cation, with  only  some  very  diminutive  ones  superiorly.  In  one 
case  there  were  paroxysms  of  dyspnoea  for  several  successive 
days  ;  they  ceased  quickly  after  the  application  of  a  blister  to 
the  neck.  In  other  instances,  when  even  the  disorganization 
was  considerable,  the  patients  lay  with  the  head  low,  and 
were  not  liable  to  greater  dyspnoea  than  when  no  such  ulcera- 
tion existed.*  The  expectoration  presented  no  peculiar  char- 
acters ;  so  that  the  only  symptoms  we  can  attribute  to  the 
morbid  alteration  we  are  considering  are  those  which  were 
experienced  by  the  subject  of  the  following  observation,  viz., 
a  sense  of  obstruction,  with  a  slight  heat  behind  the  upper 
portion  of  the  sternum. 

*  Paroxysms  of  dyspnœa  have  been  generally  enumerated  among  the 
symptoms  of  ulcerated  trachea.  —  Louis. 


240  SYMPTOMS. TRACHEA,    ULCERATIONS;       [Part  II, 


FIFTEENTH    OBSERVATION. 

302.  A  GIRL,  get.  23,  of  a  lymphatic  and  sanguineous 
temperament,  large  proportions,  robust,  not  liable  to  colds, 
and  never  having  had  a  serious  illness,  had  for  the  last  six 
months  labored  under  the  majority  of  the  symptoms  of  phthisis. 
The  expectoration  and  dyspnœa  had  commenced  with  the 
cough  ;  night  perspirations  had  existed  for  some  time  ;  there 
had  been  occasional  diarrhœa,  but  no  loss  of  appetite.  Ema- 
ciation, however,  had  been  evident  from  the  very  commence- 
ment of  the  cold.  She  had  had  no  haemoptysis  or  pain  in 
the  chest,  when,  without  any  evident  cause,  she  was  suddenly 
atacked  with  violent  shiverings,  succeeded  by  heat,  pain  in 
the  right  side,  and  extreme  dyspnœa.  These  symptoms  con- 
tinued, and  on  the  eleventh  day  from  their  commencement, 
she  was  admitted  into  the  hospital  of  La  Charité,  December 
9th,  1822. 

10th.  Expression,  animated  ;  frontal  headache  ;  lassitude 
in  the  limbs  and  loins  ;  pain  between  the  thyroid  cartilage 
and  OS  hyoides  ;  deglutition,  difficult  ;  slight  hoarseness  ;  a 
constant  acute  pain  in  the  right  side  of  the  chest,  augmented  by 
cough  and  pressure,  with  evidently  increased  local  tempera- 
ture. There  was  extreme  dyspnœa  ;  she  lay  with  her  head 
much  elevated.  Coarse-like  bronchial  respiration  under  the 
clavicles,  tracheal  posteriorly  and  laterally,  in  the  lower  half  of 
the  right  side,  where  there  were  œgophony  and  dull  sound  on 
percussion.  Cougii,  fi-equent,  discordant,  accompanied  with 
a  milky  looking  and  slightly  aerated  expectoration,  mingled 
with  some  opaque  masses,  thick,  and  streaked  with  white 
lines  ;  pulse,  one  hundred,  quick,  pretty  full  ;  heat   of  skin, 


Chap.  4.]     OPPRESSION  behind  sternum,  &ic.  241 

moderate  ;  tongue,  rather  red  on  edges,  whitish  in  the  centre  ; 
sensation  of  dryness  with  shght  redness  in  the  pharynx  ;  thirst, 
moderate  ;  anorexia  ;  occasional  nausea  with  cough  ;  consti- 
pation. 

(V.  S.  §  xij.  ;  decoction  of  triticum  repens  with  nitre  ; 
gum  potion  ;  two  emolHent  enemas). 

The  bleeding  was  repeated  on  the  two  following  days,  and 
twenty  leeches  were  applied  to  the  side  without  success.  On 
the  13th,  a  blister  five  inches  square  was  ordered,  and  on  the 
14th,  the  intensity  of  nearly  all  the  symptoms  was  dimin- 
ished ;  the  pulse  was  less  accelerated  ;  the  pains  in  the  neck 
and  the  alteration  of  the  voice  persisted. 

The  improvement  continued  on  the  following  days  ;  on  the 
3d  of  January  no  segophony  could  be  detected.  There  was 
evident  pectoriloquy  between  the  scapula  and  vertebral  column 
on  the  right  side  ;  its  existence  on  the  left  was  doubtful.  Du- 
ring the  night  she  had  two  paroxysms  of  dyspnoea.  A  few 
days  afterwards  the  segophony  was  again  heard.  February 
28th.  Percussion,  perfectly  flat  under  the  right  clavicle;  ab- 
sence of  respiratory  murmur  there  ;  considerable  dyspnœa, 
and  the  patient  lay  with  the  head  raised.  These  symptoms 
continued  until  death,  which  took  place  on  the  21st  of  March. 
The  pulse  was  more  or  less  accelerated  ;  heat  of  skin,  varia- 
ble, greatest  in  the  evening  and  at  night.  Some  irregular 
rigors  almost  every  day,  with  night  perspirations,  which  were 
frequently  accompanied  with  sudamina. 

The  fixed  pain  between  the  thyroid  cartilage  and  os  hyoides 
was  constant,  though  varying  in  intensity  ;  the  voice  was 
always  modified,  and  aphonia  existed  the  last  twenty  days. 
The  pharynx  was  slightly  red  but  not  swelled  ;  the  deglutition 
was  at  first  difficult,  then  easy,  and  again  difficult  during  the 
G  2 


242  SYMPTOMS. TRACHEA,    ULCERATIONS;        [Part  11 , 

last  few  weeks.  To  these  symptoms  another  was  added  on 
the  10th  of  January.  She  complained  of  having  experienced 
for  some  hours  a  sense  of  obstruction  behind  and  immediately 
above  the  sternum,  exciting  occasional  efforts  to  swallow  ; 
there  was  no  sense  of  pricking  or  heat  in  the  same  region  ; 
the  pain  in  the  throat  had  ceased.  This  state  of  things  con- 
tinued during  several  weeks,  and  on  the  7th  of  February  and 
following  days,  an  acute  pain  was  felt  in  the  course  of  the 
trachea  during  respiration.  At  the  same  period,  some  cere- 
bral symptoms  announced  a  fresh  complication.  On  the  11th 
of  February,  there  were  giddiness,  headache,  and  for  some 
minutes  loss  of  consciousness.  No  paralysis  succeeded,  but 
the  headache  persisted,  and  on  the  next  day  the  vertigo 
returned.  28th.  A  sensation  similar  to  that  resulting  from  a 
violent  bruise  on  the  right  side  of  the  face.  On  the  2d  of 
March,  the  mouth  was  drawn  to  the  left,  the  right  arm  very 
feeble  ;  no  affection  of  the  right  leg.  The  feebleness  soon 
after  extended  to  the  whole  of  the  right  side,  and  the  superior 
and  inferior  extremities  were  successively  affected  by  pain, 
numbness,  and  loss  of  temperature.  Some  uncomfortable 
prickings  in  the  right  eye,  followed  by  a  sense  of  heat  ;  the 
pupil  of  the  same  side,  which  was  at  first  the  larger  of  the  two, 
became  very  small.  On  the  8th,  while-  laughing  with  her 
companions,  she  was  seized  with  loss  of  consciousness  for  some 
minutes.  No  sensible  increase  of  cerebral  symptoms  on  the 
following  day.  16th.  Considerable  prostration  ;  paralysis  of 
the  right  side,  almost  complete  ;  tongue,  deviated  to  the  same 
side.  19th.  Loss  of  speech,  but  she  indicated  her  wants  by 
gestures  ;  delirium  during  the  night  and  restlessness  on  the  20th. 
This  continued  the  following  night.  21st.  Alternate  rigidity 
and  spasmodic  movements  in  the  right  arm,  and  at  moments 
slight  stiffness  in  the  left.     This  continued   until  four  o'clock 


Chap.  4.]     OPPRESSION  behind  sternum,  &c.  243 

in  the  evening,  when  rattling  respiration  came  on,  and  death 
took  place  at  midnight. 

The  appetite,  at  first  good,  soon  almost  entirely  ceased. 
During  part  of  February,  there  were  pains  in  the  epigastrium 
and  right  iliac  fossa.  Some  nausea  at  considerable  intervals. 
Afterwards  the  desire  for  attending  to  the  necessities  of  nature 
rarely  came  on,  and  when  it  did  it  was  slight.  February  7th. 
Tongue,  rather  red,  and  covered  with  numerous  apthous 
patches,  which  were  easily  removed,  and  were  again  secreted 
in  the  beginning  of  March.  12th.  Tongue,  natural  ;  some 
nausea  and  bilious  vomitings  ;  the  diarrhœa  was  almost  con- 
stantly present,  but  slight,  with  occasional  colic  and  tenesmus. 

Emollient  drinks,  Sydenham's  white  decoction  or  rice  water, 
and  mustard  pediluvia  were  prescribed  according  to  the  symp- 
toms. Leeches  were  applied  to  the  labia  at  the  commence- 
ment of  the  cerebral  symptoms. 

Opening  of  the  corpse  thirty-five  hours  after  death. 

Exterior.  —  Considerable,  but  not  extreme  emaciation. 
Nothing  else  remarkable. 

Head.  —  Bones  of  skull,  very  thick.  Beneath  the  arach- 
noid, covering  the  upper  and  middle  portion  of  the  left  hemi- 
sphere, over  an  extent  of  four  square  inches,  was  a  membranous, 
yellow,  concrete  substance,  about  a  line  in  thickness,  appar- 
ently developed  in  the  pia  mater.  The  cerebral  substance 
was  a  little  soft,  but  not  injected.  There  was  a  spoonful  of 
serum  in  each  lateral  ventricle.  The  inferior  half  of  the  sep- 
tum lucidum  was  softened,  pulpy,  and  its  fragments  floated 
in  the  fluid  of  the  ventricles. 

Neck.  — The  mucous  membrane  of  the  laryngeal  surface  of 
the  epiglottis  was  entirely  destroyed.  Superficial  ulceration  of 
the  upper  vocal  cord  of  the  right  side  ;  that  on  the  left  side 


244  SYMPTOMS.  —  TRACHEA,    ULCERATIONS;       [Part  II, 

was  almost  annihilated  ;  the  lower  was  less  extensively  affected. 
The  lining  membrane  of  the  muscular  portion  of  the  trachea 
was- destroyed  ;  the  muscular  fibres  were  denuded,  and  more 
or  less  thickened  in  nearly  their  whole  extent.  Ten  of  the 
cartilaginous  rings  were  exposed,  as  if  the  mucous  membrane 
had  been  artificially  removed.  The  remaining  part  was  soft- 
ened, and  of  a  light  pink  color. 

Thorax.  —  Right  lung,  adherent  at  its  summit  by  a  thick 
membranous  band  ;  lower  down  it  was  covered  by  a  false 
membrane,  about  one  line  thick,  with  an  undulated  surface, 
continued  over  the  diaphragmatic  and  costal  pleurae,  and  en- 
closing two  quarts  of  limpid  fluid.  In  the  upper  lobe  there 
were  two  cavities  nearly  empty,  about  the  size  of  a  nut,  commu- 
nicating with  the  bronchia,  and  numerous  softened  tubercles. 
The  two  other  lobes  presented  a  great  many  grey  granulations. 
The  left  lung  offered  several  inequalities  at  its  surface,  which 
were  caused  by  tubercles  ;  there  were  some  excavations  at  its 
summit,  rather  smaller  than  those  on  the  right  side  ;  the  lower 
lobe  was  only  slightly  engorged.  Five  or  six  ounces  of  red- 
dish-colored fluid  in  the  pericardium  ;  the  heart  was  extremely 
soft,  of  moderate  volume,  and  of  a  deep  livid  color;  aorta, 
healthy. 

Abdomen. — Liver,  fatty  and  voluminous;  bile  in  gall- 
bladder, rather  thick,  and  of  a  brownish  color  ;  lining  mem- 
brane of  stomach,  covered  with  some  thick  and  tenacious  mu- 
cus, alternately  red  and  softened  in  the  great  cul-de-sac  ; 
healthy  within  three  inches  of  the  pylorus,  thin  and  mamillated 
elsewhere  ;  duodenum,  natural  ;  numerous  pale,  yellowish 
miliary  granulations  under  the  mucous  membrane  of  the  small 
intestine,  in  the  upper  four  feet  ;  farther  down  their  number 
diminished,  and  they  ceased  altogether  in  the  lower  third  ; 
middle-sized  ulcerations  throughout  the  whole  intestine,  inter- 


Chap.  4.]     OPPRESSION  behind  sternum,  &;c.  245 

spersed  with  tubercular  granulations,  and  separated  by  inter- 
vals of  from  three  to  eight  inches  ;  their  bottom  was  blackish, 
and  the  mucous  membrane  a  little  detached  and  thickened  on 
the  edges  in  the  greater  number.  The  last  ulceration,  which 
included  the  ileo-csecal  valve,  and  the  whole  circumference  of 
the  intestine  was  by  far  the  most  extensive.  The  correspond- 
ing muscular  coat  was  thickened  and  denuded.  There  were 
several  ulcerations  in  the  large  intestine,  where  the  lining 
membrane  was  pale  and  soft  as  mucus  ;  these  ceased  within 
three  inches  of  the  anus.  The  lowest  encircled  the  gut,  and 
was  about  four  lines  wide.  All  the  mesenteric  glands  were 
enlarged  and  changed  into  tuberculous  matter  which  was  not 
softened  ;  some  of  the  mesocolic  were  in  the  same  state. 
The  remaining  viscera  were  healthy. 

303.  Notwithstanding  the  number  of  the  various  alterations 
which  have  been  described,  each  gave  rise  to  its  peculiar  symp- 
toms. Phthisis  presented  its  own  ;  those  of  pleurisy  were  dis- 
tinctly marked.  The  same  may  be  said  of  the  morbid  state 
of  the  brain  and  its  membranes.  The  ulcerations  of  the  epi- 
glottis were  pointed  out  by  the  situation  of  the  pain,  above 
and  on  a  level  with  the  upper  part  of  the  thyroid  cartilage  ; 
those  of  the  larynx  by  the  change  of  the  voice,  and  subse- 
quent aphonia.  Lastly,  the  obstruction  complained  of  by  the 
patient  behind  the  upper  portion  of  the  sternum,  and  the  pain 
in  the  course  of  the  trachea  during  inspiration,  justified  the  sus- 
picion of  some  more  or  less  considerable  alteration.  We  shall 
presently  find  that  this  last  symptom  existed  also  in  cases 
where  the  mucous  membrane  of  the  trachea  was  merely  red 
and  slightly  thickened  ;  an  additional  reason  for  regarding  it 
of  importance  in  the  diagnosis  of  the  lesion  we  are  now  con- 
sidering.    The  dyspnœa  was  urgent  ;  but  the  state  of  the 


246  SYMPTOMS. TRACHEA,    ULCERATIONS  ;       [Part  II, 

lung  and  pleurae  of  the  right  side  sufficiently  explain  its  ex- 
istence, SO  that  we  need  not  attribute  it  to  the  ulceration  of 
the  trachea  ;  besides,  it  coincided  with  the  attack  of  pleurisy, 
which  came  on  when  probably  the  affection  of  the  trachea  did 
not  exist. 

The  anorexia,  nausea,  pain  in  the  epigastrium,  were  in 
unison  with  the  condition  of  the  gastric  mucous  membrane. 
The  diarrhoea,  though  not  copious,  had  persisted,  almost  un- 
interruptedly, nine  months  ;  and  we  found  the  intestinal 
ulcerations,  without  being  very  large,  by  no  means  small,  and 
very  numerous,  especially  in  the  small  intestine.  The  tenes- 
mus complained  of  by  the  patient,  though  not  urgent,  indi- 
cated some  alteration  of  the  mucous  membrane  of  the  rectum  ; 
and  we  have  accordingly  seen  it  the  seat  of  ulcerations,  one 
of  which  was  remarkable  for  its  annular  form. 

It  is  possible  then,  in  some  instances,  as  we  have  before 
remarked,  to  recognise  the  greater  number  of  the  complica- 
tions which  arise  in  the  course  of  chronic  diseases,  even  when 
general  debility  is  considerable. 

In  the  following  observation,  the  affection  of  the  trachea 
was  still  more  pronounced  than  in  the  one  which  precedes, 
without,  however,  giving  rise  to  any  appreciable  symptoms. 


SIXTEENTH     OBSERVATION. 

304.  A  TAILOR,  a3t.  24,  of  a  weak  constitution,  not  liable 
to  colds,  received  in  1814  a  kick  from  a  horse  in  the  region 
of  the  pubes.  A  tumor  of  a  very  chronic  nature  succeeded, 
opened  spontaneously,  and  gave  rise  to  a  fistula,  which  for 
nine  years  was  alternately  closed   or  discharging.     He  was 


Chap.  4.]  CAUSING  NO  symptoms.  247 

admitted  into  the  hospital  of  La  Charité,  February  16th,  1824, 
having  experienced  the  last  five  weeks  pains  in  the  upper  part  of 
the  thighs,  which  rendered  walking  difficult.  For  nine  months 
he  had  coughed  and  expectorated,  and  he  had  had,  at  times, 
slight  haemoptysis.  During  the  last  two  months,  the  expec- 
toration had  been  difficult,  and  the  sputa  seemed  to  lodge  in 
the  larynx,  where  there  was  a  sensation  of  dryness.  Diar- 
rhœa  had  been  rather  copious  for  more  than  two  months, 
after  which  the  appetite  had  almost  disappeared. 

17th.  Face,  pale  ;  mind,  active  ;  great  debility,  and  almost 
extreme  emaciation  ;  pains  in  the  upper  part  of  the  thighs  in- 
creased by  any  attempt  to  walk,  which  the  patient  found  it 
almost  impossible  to  do.  The  fistula,  which  was  situated  just 
above  the  symphisis  pubis,  discharged  a  small  quantity  of  very 
thin  pus.  Little  cough  ;  expectoration,  scanty,  greenish, 
opaque,  mingled  with  a  certain  quantity  of  limpid  mucus  ;  not 
much  dyspnœa  ;  percussion,  every  where  clear  ;  no  pectoril- 
oquy or  tracheal  respiration  ;  a  slight  mucous  râle  was  heard^ 
but  confined  to  the  upper  part  of  the  chest  ;  voice,  natural  ; 
no  pain  in  the  larynx  or  trachea  ;  pulse,  rather  quick  ;  heat, 
moderate  ;  rigors,  rare  ;  perspirations,  copious  ;  mouth,  clam- 
my ;  tongue,  rather  red  on  edges;  anorexia,  almost  complete  ; 
little  thirst  ;  abdomen,  yielding  and  without  pain  ;  six  liquid 
stools. 

From  this  period  up  to  the  25th  of  April,  when  death  took, 
place,  no  uneasy  sensation  was  felt  in  the  neck.  He  only 
complained  of  a  slight  soreness  of  the  th'roat  a  few  days  before 
the  fatal  termination.  The  pharynx  was  always  natural,  and 
no  change  was  observed  in  the  voice.  The  expectoration 
continued  as  before.  On  the  6th  of  March,  percussion  was 
clearer  posteriorly  on  the  right  side  than  on  the  left;  there 
was  also  slight  resonance  of  voice  under  the  right  clavicle,  and 


248  SYMPTOMS.  TRACHEA,    ULCERATIONS  J       [Part  11, 

mucous  râle  under  the  left.  2-2d.  Percussion  in  the  latter 
region,  completely  dull  ;  the  respiration  there  was  tracheal, 
with  imperfect  pectoriloquy.  The  patient  was  constantly 
lying  on  his  back. 

The  perspirations  continued,  notwithstanding  the  use  of  the 
acetate  of  lead  in  gradually  increased  doses  ;  pulse,  more  or 
less  accelerated  ;  rigors,  present  almost  every  evening. 

The  appetite  rapidly  increased,  the  patient  eating  the  half 
of  the  usual  house  allowance  of  bread  and  vegetables  in  the 
beginning  of  March  ;  this  was  the  case  to  the  last. 

Up  to  the  19th  of  April  the  diarrhœa  was  inconsiderable, 
but  it  then  suddenly,  and  without  apparent  cause,  became 
copious.  On  the  following  evening  he  was  seized  with  ex- 
tremely acute  pains  in  the  abdomen,  followed  by  prolonged 
rigors  and  frequent  nausea.  21st.  Much  less  pain  ;  belly, 
tympanitic  :  tongue,  red  ;  slight  alteration  of  expression.  22d. 
Pain  had  ceased  ;  abdomen,  sunk  ;  stools,  numerous,  with 
extreme  weakness  ;  and  on  the  25th  death  took  place,  after 
an  hour's  struggle,  at  ten,  a.  m. 

Diascordium,  julep  and  opium  were  principally  prescribed. 

Opening  of  the  corpse  twenty-two  hours  after  death. 

Exterior.  —  The  rami  of  the  pubes  were  denuded  of  their 
periosteum,  and  had  the  aspect  of  a  substance  which  has  been 
eaten  by  ants,  and  were  surrounded  by  a  thin,  greyish  and  rather 
fœtid  pus  ;  the  attachment  of  the  muscles  to  the  descending 
ramus  was  destroyed  ;  those  forming  the  boundaries  of  the 
abscess  were  greyish  and  greenish,  covered  by  a  detritus  of  the 
same  color  and  softened.  The  abscess  extended  as  low  down 
as  the  middle  of  both  thighs. 

Head.  — Two  small  spoonsful  of  fluid  over  the  upper  por- 
tion of  the  arachnoid  ;    slight  sub-arachnoidean  infiltration  j 


Chap.  4.]  CAUSING    NO    SYMPTOMS.  249 

pia  mater,  slightly  injected  ;    brain,  healthy  ;  a  spoonful  of 
serum  in  each  lateral  ventricle. 

Neck.  —  Three  superficial  ulcerations  on  the  laryngeal 
surface  of  the  epiglottis  ;  the  intervening  mucous  membrane, 
healthy  ;  a  small  ulceration  at  the  junction  of  the  cordae 
vocales  ;  lining  membrane  of  the  trachea,  pale  and  ulcerated  ; 
the  ulcerations  increased  in  number  and  size  from  above  down- 
wards. Many  of  the  cartilaginous  rings  were  denuded;  in 
some  there  were  small,  lenticular  excavations  ;  twelve  were  in 
some  parts  much  thinned  ;  three  were  completely  destroyed  for 
about  a  line.  The  muscular  fibres  corresponding  to  the  soft- 
ened portions  were  exposed  and  nearly  destroyed,  where  three 
of  the  ulcerations  existed. 

Chest.  —  Universal  adhesions  of  both  lungs.  The  upper 
lobe  of  the  left  lung  was  indurated,  impermeable  to  the  air, 
with  the  exception  of  a  very  thin,  superficial  layer  ;  it  pre- 
sented a  middle-sized  excavation  in  its  summit,  partially  in- 
vested by  a  red,  firm,  false  membrane,  lying  on  some  grey,  semi- 
transparent  substance,  interspersed  with  tubercles.  The  cavity 
contained  a  turbid,  thick  and  greyish  fluid,  and  communicated 
with  the  bronchia,  which  were  here  redder  and  more  thick- 
ened than  elsewhere.  The  remainder  of  the  lobe  offered 
some  small  excavations,  and  was  almost  entirely  transformed 
into  the  grey  matter,  which  was  thickly  sprinkled  with  tuber- 
cular granulations.  Lower  lobe,  healthy.  The  same  altera- 
tions existed  on  the  right  side,  but  were  less  extensive. 
There  were  some  small  superficial  ulcerations  in  the  left 
bronchia  ;  heart,  a  third  less  than  usual  ;  aorta,  natural. 

Abdomen.  —  Half  a  quart  of   turbid  inodorous  fluid  in 
the  abdominal  cavity  ;    no  communication   with  the  abscess 
behind  the  pubis  ;  slight  adhesions  between  some  of  the  con- 
H  2 


250  SYMPTOMS. TRACHEA,    ULCERATIONS  ;      [Part  II, 

volutions  of  the  small  intestines  by  means  of  a  soft,   yellow- 
colored  false  membrane,  which   also  covered  the  bladder  and 
rectum.      The   subjacent   peritoneum  was   of  a  bright  red  ; 
liver,  small  and  healthy  ;  bile,   rather  abundant,   viscid,  and 
green  colored.     The  stomach   contained   a   small   quantity  of 
yellow  fluid,  was  voluminous,  and  its  mucous  membrane  pale, 
and  of  a  perfectly  natural  firmness  and  thickness.    At  the  origin 
of  the  small  intestine  there  were  numerous  opaque,  submucous 
miliary  granulations,  and  throughout  its   whole  length  ulcera- 
tions increasing  in  size  and   number  from    above   downwards. 
If  small,  they  were  usually  partially  concealed  by  the  valvules 
conniventes;  when  larger,  they  occupied  the  glandular  patches, 
of  which  some  were   destroyed,  whilst  others  presented  small 
ulcerations,  more   or  less   approximated,   with   some   slightly 
softened  tubercles.     The   muscular  tunic   was  not  denuded, 
except  where  it  corresponded  to  some  large   ulcerations,  and 
then  only  partially.      In  the  caecum  and  transverse  colon,  there 
were  two   very  extensive  ulcerations.      They   encircled  the 
intestine,  and  were   at  least  three  inches  long,   presenting  a 
greyish   rugged  surface,   formed   by  the   submucous  cellular 
layer,  about  half  a  line  thick,  while  the  corresponding  muscu- 
lar layer  was   twice   its  usual  thickness.     Between  these  two 
large  ulcerations  there   were  six  smaller  ones.     The  descend- 
ing colon  and  rectum  were  occupied   by  others,  tolerably  nu- 
merous, narrow,  semi-circular  and  dark  colored.     The  mucous 
membrane  was  red  and  of  a  moderate  consistence  in  this  last 
part.     Mesenteric  glands,  voluminous,  red,  and  partly  tuber- 
culated.     This  was  the  case  with  those  of  the  mesocaBcum  and 
mesocolon,  corresponding  to  the  ulcerations.    The  other  viscera 
of  the  abdomen  were  healthy. 

305.  In  this,  as  in  the  preceding  instance,  there  were  ulcer- 


Chap.  4.  CAUSING  NO  symptoms.  251 

ations  of  the  epiglottis,  larynx  and  trachea.  They  were  slight 
in  the  first  two,  but  in  the  last  they  were  extensive,  deep, 
and  accompanied  with  partial  destruction  of  the  fibro-carti- 
lages  ;  but  none  of  these  lesions  were  indicated  by  the  symp- 
toms. It  was  in  vain  that  we  attempted  by  questions  to  dis- 
cover the  existence  of  any  symptoms  which  could  be  referred 
to  ulceration  of  the  trachea.  We  arrived  at  negative  resuhs 
alone,  and  our  failure  cannot  be  attributed  to  a  deficiency  of 
intelligence  in  the  patient,  whose  memory  was  good  and  mind 
active,  nor  to  his  extreme  weakness.  In  proof  of  the  accuracy 
of  this  last  assertion,  we  would  refer  to  our  observations  of 
croup  in  the  adult,*  where  weakness  was  almost  constantly 
present,  but  in  which  cases  a  more  or  less  severe  pain  in  the 
trachea  was  invariably  complained  of.  Among  others,  we 
remember  the  case  of  a  woman  who  died  from  phthisis,  and 
who  was  attacked  v/itb  croup  when  the  emaciation  was  at  its 
maximum,  and  who  complained  of  heat  and  pain  in  the  course 
of  the  trachea  from  the  very  commencement  of  the  symptoms 
of  the  afi:ection.  it  is  probable,  in  the  present  instance,  that 
the  absence  of  symptoms  was  owing  to  the  extremely  slow 
progress  of  the  disease. 

306.  Although  we  are  unable  to  determine  the  exact  period 
v/hen  the  morbid  state  of  the  trachea  commenced,  we  thhik, 
however,  it  must  have  been  of  considerable  duration.  Of  this 
we  have  in  some  measure  a  proof  in  the  solution  of  continuity 
of  many  of  the  fibro-cartilages,  and  in  the  almost  total  destruc- 
tion of  the  muscular  membrane  of  the  trachea  in  difiTerent 
points,  for  these  disorders  must  have  required  some  time  for 
their  development.     It  may  also  be  remarked,  that  this  is  the 

*  Mémoire  sur  le  Croup  considéré  chez  l'Adulte.  —  Vide  Recherches  Ana- 
tomico  Pathologiques  sur  diverses  Maladies.    8vo.    Paris.   1826.  —  Louis. 


252  SYMPTOMS.  —  TRACHEA.      [Part  11, 

first  instance  where  we  have  seen  the  complete  destruction  of 
portions  of  the  fibro-cartilages,  and  where  the  destruction  of 
the  muscular  layer  was  so  considerable. 

307.  Let  us  also  remark,  that  the  bronchia  were  only  ulcer- 
ated on  the  side  corresponding  to  the  large  excavation,  but 
they  were  redder  and  thicker  there  than  elsewhere  ;  and  thus 
we  have  confirmed  what  we  have  advanced  on  the  probable 
cause  of  ulceration  in  the  air  passages,  and  the  influence  of 
the  expectorated  matter  on  their  inflammatory  appearance 
(53). 

308.  The  inconsiderable  diarrhœa  until  within  a  few  days 
of  death,  notwithstanding  the  number  and  size  of  the  intestinal 
ulcerations,  must  not  be  overlooked.  This  great  disproportion 
between  the  symptoms  and  lesion  is  not  common,  and  may 
perhaps  be  attributed  to  the  fact  of  the  submucous  layer  in 
the  ulcerated  portions  not  being,  as  it  usually  is,  destroyed  ; 
indeed,  this  is  the  only  example  of  large  ulcerations  we  have 
seen,  where  the  thickened  muscular  tissue  was  not  more  or 
less  extensively  denuded. 

309.  When  inflammation  of  the  lining  membrane  oj 
the  trachea  (characterized  conmionly  by  a  bright  red  color, 
sometimes  conjoined  with  a  slight  thickening  or  softening), 
existed  without  ulcerations,  in  some  instances  the  patients, 
complained  of  a  more  or  less  acute  pain,  accompanied  with 
sense  of  heat  in  the  neck;  this  was  observed  in  three  out  of 
seventeen.  Five  others  suffered,  during  some  time,  from 
pains  of  the  throat  and  larynx,  although  no  morbid  change 
could  be  detected  in  these  parts. 

310.  If  we  compare  the  symptoms  complained  of  in  the 
first  three  cases  with  those  we  have  observed  in  croup,  where 
heat  and  pain  were  almost  constantly  present,  we  feel  justified 


Chap.  5.]  STOMACH.  253 

in  regarding  them,  whenever  they  occur  in  the  course  of 
phthisis,  as  indications  of  inflammation  of  the  mucous  mem- 
brane of  the  trachea.  Perhaps  we  may  also  refer  to  the  same 
cause  the  existence  of  pain  referred  to  the  larynx  or  fauces, 
when  the  deglutition  and  voice  are  not  affected  ;  for  pain  in 
the  throat,  accompanying  inflammation  of  the  mucous  mem- 
brane of  the  trachea,  is  perfectly  analogous  to  what  is  felt  in 
the  glans  penis  from  calculus  in  the  bladder. 

311.  Hoarseness  was  sometimes  present  when  there  was 
neither  ulceration  nor  inflammation  of  the  laryngeal  mucous 
membrane,  but  it  was  then  transitory,  occurred  at  different 
periods  of  the  disease,  and  was  not  accompanied  by  pain  in 
the  throat. 

In  conclusion  then,  we  find  that  in  the  majority  of  cases 
ulcerations  of  the  larynx  gave  rise  to  their  peculiar  symptoms: 
—  that  those  of  the  epiglottis,  if  not  extensive,  were  usually 
latent  :  —  that  those  of  the  trachea  were  only  once  character- 
ized by  special  symptoms  :  —  that  simple  inflammation  of  the 
mucous  membrane  of  the  trachea  frequently  excited  heat  and 
pain,  the  latter  being  sometimes  referred  to  the  throat  or 
larynx. 


CHAPTER    V. 


SYMPTOMS  OF  THE  VARIOUS  ALTERATIONS  OF  THE  GASTRIC 
MUCOUS  MEMBRANE. 

312.  At  different  periods  of  phthisis,  the  patients  experi- 
enced symptoms  of  variable  intensity  referrible  to  the  stomach. 
As  these  varied  with  the  lesions  of  the  mucous  membrane,  we 
shall  describe  them  under  corresponding  articles. 


254  SYMPTOMS.  —  STOMACH  ;  [Part  II, 


ARTICLE    I. 

SyMPTOMS    OF    SOFTENING     WITH     DIMINISHED     THICKNESS    OF    THE 
MUCOUS  MEMBRANE  OF  THE  STOMACH.* 

313.  At  a  variable  period  (seldom  at  the  commencement 
of  phthisis),  most  frequently  tvA'O,  four,  five,  six,  or  more 
months  preceding  the  fatal  termination,  the  patients  who  were 
attacked  by  the  morbid  alteration  we  are  considering,  lost  their 
appetite,  and  soon  after  experienced  pains  in  the  epigastrium, 
which  were  often  very  acute.  Some  days,  or  even  months 
subsequently,  they  had  nausea,  then  vomiting,  or  these  last 
two  symptoms  commenced,  and  were  succeeded,  after  one  or 
more  weeks,  by  pain.  It  was  rare  to  see  all  these  symptoms 
manifest  themselves  at  the  same  time.  In  many  instances 
they  were  intense  from  the  beginning  ;  in  others,  their  devel- 
opment was  gradual  ;  most  frequently  they  became  more  and 
more  insupportable,  and  continued  with  variable  remissions 
until  death. 

314.  These  symptoms  were  present  in  almost  all  the  cases, 
but  differed  in  intensity.  In  sixteen  cases  out  of  nineteen  there 
was  nausea  with  epigastric  pain,  and  in  fifteen,  vomiting.  In 
three  there  were  no  very  distinct  gastric  symptoms,  notwith- 
standing the  serious  nature  and  extent  of  the  alterations  of  the 
mucous  membrane  (Obs.  10  (bis),  26).  In  some,  the  pain, 
nausea  and  vomiting  were  preceded  during  one,  two,  or  three 
years  by  disordered  digestion. 

315.  The  pain  was  pungent,   lancinating,  and  occasionally 

**  For  greater  detail  we  refer  the  reader  to  our  Recherches  Pathologiques, 
already  cited,  First  Memoir.  —  Louis. 


Chap.   5.]     SOFTENING,  &C.,   OF  MUCOUS  MEMBRANE.  255 

accompanied  with  heat  ;  it  produced,  in  some  instances,  the 
feehng  of  a  bar  stretching  across  the  epigastrium  ;  in  others  it 
could  not  be  compared  to  any  thing.  It  was  usually  contin- 
ued and  progressive  in  intensity.  It  was,  however,  at  times 
intermittent,  ceasing  altogether  a  few  days  before  death. 
When  very  acute,  it  engrossed  the  patient's  attention,  and  no 
questions  foreign  to  the  point  were  answered  willingly,  so  that 
unless  we  had  carefully  examined  all  the  functions,  the  exist- 
ence of  phthisis  might  for  a  time  have  been  overlooked.  The 
acuteness  of  the  pain  was  the  more  remarkable,  since  we  ob- 
served it  in  instances  where  general  debility  was  considerable, 
and  the  complications  numerous.  The  slightest  pressure  upon 
the  epigastrium  was  insupportable,  and  liquids  of  moderate 
temperature  appeared  as  if  iced.  Who  can  believe  after  this 
that  the  mucous  membrane  of  the  stomach  is  very  insensible, 
or  that  it  shows  its  sufferings  in  a  very  different  manner  from 
that  of  other  organs?  The  pain  was  not  sensibly  alleviated  by 
opium  ;  it  was  sometimes  diminished  for  several  successive  days 
by  Seltzer  water.*  It  was  in  one  instance  calmed  momen- 
tarily, a  short  time  after  it  commenced,  by  a  cordial  draught 
(Obs.  31). 

316.  The  vomitings  were  almost  always  bilious,  commonly 
rare  at  the  beginning,  but  increasing  in  frequency  as  the 
disease  proceeded. 

317.  Light  food  was  in  some  cases  digested  by  some  with- 
out much  difficulty,  while  others  could  only  venture  to  eat  at 
a  particular  hour,  generally  in  the  morning  (Obs.  32).  The 
appetite  occasionally  improved  for  one  or  more  weeks,  though 
the  mucous  membrane  was  seriously  and  extensively  affected 

*  Seltz  on  the  lower  Rhine.  The  water  contains,  —  Carbonic  acid  213 
parts  ;  carb.  sod.  5  ;  carb.  magnes.  6  ;  carb.  of  lime  78  ;  mur.  sod.  13,  in  8,94D 
parts  of  water,  —  Cowan. 


256  SYMPTOMS.  —  STOMACH  ;       [Part  II, 

(Obs.  39).  But  sooner  or  later,  in  the  majority  of  instances, 
no  kind  of  food  could  be  supported,  and  even  pure  water  was 
rejected  ;  so  that  the  dread  of  vomiting  made  the  patients 
resist  the  cravings  of  thirst. 

318.  Among  the  symptoms  therefore  indicating  the  soft- 
ened condition  and  diminished  consistence  of  the  gastric  mu- 
cous membrane,  anorexia,  nausea,  vomitings,  and  epigastric 
pains  may  be  enumerated.  They  afford  us  a  proof  that  the 
lesions  of  the  stomach,  in  common  with  those  of  the  other 
organs,  are  characterized  by  pain  and  disordered  functions. 

319.  When  the  symptoms  we  have  described  have  been 
constantly  present  for  some  time,  say  three  or  four  weeks,  we 
may  regard  as  certain  the  existence  of  a  thinned  and  softened 
mucous  membrane.  Daily  experience  convinces  us  of  the 
truth  of  this  assertion. 

320.  Many  of  the  observations  scattered  through  the  course 
of  this  volume  (Obs.  31,  32,  39,  Sic),  may  be  cited  in  sup- 
port of  what  we  advance,  but  the  following  appears  more  than 
usually  applicable. 


SEVENTEENTH     OBSERVATION. 

A  WOMAN,  set.  35,  mother  of  several  children,  of  a  weak  con- 
stitution, and  not  liable  to  colds,  entered  the  hospital  of  La 
Charité,  July  13th,  1824  ;  she  had  been  confined  ten  months 
before,  and  had  suffered  mucli  in  the  left  knee  the  last  six  ;  it 
presented  all  the  rational  symptoms  of  a  white  swelling.  She 
was  in  the  surgical  ward,  and  had  two  moxas  applied,  which 
were  followed  by  cessation  of  the  pain  and  diminished  volume 
of  the  joint,  which  subsequently  became  ankylosed.     On  the 


Chap.  5.]      SOFTENING,  k-C,  OF  MUCOUS  MEMBRANE.  257 

5th  of  November  she  was  transferred  into  the  wards  of 
M.  Chomel,  and  in  addition  to  the  preceding  details,  we 
learned  that  on  the  1st  of  August,  after  a  great  mental 
disturbance,  she  was  seized  with  alternate  rigors  and  flush- 
ings, cough,  epigastric  pains,  nausea,  ^and  occasional  vom- 
iting ;  that  at  the  same  time  there  had  been  slight  aug- 
mentation of  thirst  and  loss  of  appetite.  These  symptoms, 
which  had  since  persisted,  were  soon  associated  with  increased 
heat  of  surface  coming  on  in  the  evenings,  night  perspirations, 
and  occasional  rigors.  The  expectoration  had  only  been  pres- 
ent since  October.  Shortly  after,  acute  pains  were  felt  in  the 
right  side  of  the  chest,  and  after  a  week's  duration  yielded 
almost  immediately  to  the  application  of  a  blister  to  the  parts. 
The  stools  were  fluid  and  frequent  during  the  last  three  days  ; 
emaciation  dated  from  the  period  of  her  last  con6nement. 

November  5th,  Expression,  rather  animated  ;  great  general 
debility,  the  patient  could  hardly  turn  herself  in  bed  ;  thirst, 
moderate  ;  anorexia,  almost  complete  ;  tongue,  natural  ;  pain  in 
epigastrium,  which  was  sensible  to  the  slightest  pressure  ;  fre- 
quent nausea,  principally  during  the  night  and  after  the  cough, 
sometimes  followed  by  bilious  eructations  ;  abdomen,  slightly 
painful  ;  evacuations,  liquid  with  previous  colic  ;  cough,  most 
troublesome  in  the  night,  and  less  frequent  during  the  day  ; 
expectoration,  white,  spumous,  floating  on  a  large  quantity  of 
clear  fluid;  respiration,  rather  accelerated;  percussion,  less 
clear  on  the  lateral,  posterior  and  lower  half  of  the  right  side 
than  on  that  of  the  other  ;  respiratory  murmur  stronger  under  the 
right  clavicle  with  occasional  crepitation  ;  pulse,  one  hundred 
and  fifteen,  small  and  weak  ;  temperature,  moderate  during 
the  day,  elevated  at  night  ;  rigors  in  the  evening  with  night 
perspirations  ;  oppression  referred  by  the  patient  to  the  epigas- 
trium, which  was  the  seat  of  much  anxiety  and  uneasiness. 
I  2 


25S  SYMPTOMS.  —  STOMACH  ;  [Part  II, 

(Solution  of  gum  syrup  ;  rice  water  with  lemon  juice  ;  a 
grain  of  opium  with  gum  potion). 

The  gastric  symptoms  continued,  and  became  daily  more 
intense.  From  the  8th  to  the  21st  of  November,  two  days 
before  death,  bilious  vomitings  occurred  frequently  in  the  four- 
and-twenty  hours,  either  accompanying  the  cough,  or  in  the 
intervals  ;  extreme  uneasiness  and  anxiety  ;  sense  of  suffoca- 
tion, with  very  acute  pains  in  the  epigastrium  ;  the  slightest 
pressure  there  insupportable.  Distaste  for  all  food  ;  the  weakest 
broth  caused  a  feeling  of  oppressive  weight  in  the  stomach. 
She  afterwards  vomited  every  thing  ;  drank  extremely  small 
quantities  at  once,  and  liquids  at  the  ordinary  temperature  ap- 
peared cold,  like  ice.  The  tongue  was  natural,  or  rather  pale, 
to  the  18th  ;  it  then  became  red,  hot,  smarting,  and  covered 
by  white  apthous  patches,  which  were  frequently  renewed. 
They  extended  to  the  lips,  inside  of  the  cheeks,  and  to  the 
soft  palate  ;  at  first  appearing  under  the  form  of  small  spots, 
like  grains  of  starch,  gradually  increasing,  and  by  their  union 
covering  the  surface.  The  stools  were  fluid,  but  not  frequent 
until  the  18th  they  then  became  suddenly  very  numerous, 
and  during  the  last  three  days  were  passed  involuntarily,  and 
were  almost  constant.  At  the  same  time  there  were  pains 
over  the  whole  abdomen,  and  especially  in  the  right  iliac 
fossa. 

The  cough  remained  stationary  ;  expectoration,  scanty  and 
spumous;  percussion  did  not  vary.  19th.  Tracheal  respira- 
tion under  the  right  clavicle,  but  no  pectoriloquy  ;  pulse, 
small,  weak  and  rapid,  except  during  the  last  four  days,  when 
it  fell  from  one  hundred  and  forty  to  one  hundred.  Great 
sensibility  to  cold.  The  patient  was  constantly  changing  her 
position  in  bed,  laboring  under  the  greatest  general  uneasiness 
and  anxiety,  so  that  at  times  she  could  hardly  tell  where  she 


Chap.  5.]  SOFTENING,  Sic,  of  mucous  membrane.  259 

was  suffering.     No  delirium  was  observed  before  death,  which 
took  place  November  23d,  at  six,  a.  m. 

Opening  of  the  corpse  twenty-six  hours  after  death. 

Exterior.  —  Extreme  emaciation.  Nothing  else  remark- 
able. 

Head. — Slight sub-arachnoidean  infiltration;  brain,  healthy  ; 
two  small  spoonsful  of  fluid  in  the  right  lateral  ventricle  ;  rather 
less  in  the  left  ;  no  other  alteration. 

Neck.  —  Epiglottis,  larynx  and  trachea,  healthy. 

Chest.  —  Left  lung,  without  adhesions,  presenting  at  the 
middle  portion  of  the  upper  lobe  a  greyish-colored  and  whitish 
mass,  about  the  size  of  a  small  hen's  egg,  composed  of  an  infi- 
nite number  of  tubercular  granulations,  separated  here  and 
there  by  a  reddish  and  slightly  granulated  tissue.  There  were 
also  in  other  parts  grey  granulations,  some  of  which  were 
immediately  beneath  the  pleura,  and  made  it  prominent. 
Right  lung,  universally  adherent  by  means  of  a  double  false 
membrane,  the  folds  of  which  were  firmly  connected  together. 
This  was  thicker  inferiorly  than  it  was  above,  and  the 
greater  part  was  transformed  into  tuberculous  matter.  There 
were  numerous  yellow  and  grey  granulations  under  the  pul- 
monary pleura,  and  especially  where  it  lined  the  interlobular 
fissures,  the  edges  of  which,  to  the  depth  of  about  a  line,  were 
converted  into  the  grey  and  semi-transparent  substance.  At 
the  summit  of  the  upper  lobe  there  was  a  middle  sized  exca- 
vation, containing  a  small  quantity  of  pus,  communicating  with 
the  bronchia,  but  not  lined  by  a  distinct  false  membrane.  The 
pulmonary  parenchyma  was  rather  firmer  in  its  immediate 
neighborhood  than  elsewhere.  The  bronchia  were  of  a  bright 
red  color  about  the  excavation  only.  Heart,  small,  healthy, 
of  a  firm  texture  ;  aorta,  natural. 


260  SYMPTOMS. STOMACH  ;  [Pai't  II, 

Abdomen.  —  Stomach,  of  moderate  volume,  containing  a 
small  quantity  of  turbid  bile  ;  the  superior  half  of  its  raucous 
membrane,  to  within  three  inches  of  the  pylorus,  was  of  an 
unequal  yellow  tinge,  and  with  the   exception  of  some  small 
spots,  soft  as   mucus  ;  in  fact,  with  the  back  of  the  scalpel 
it  could  be  scraped  off  like  viscid  mucus.     The  softened  part 
was  much  thinner  than  natural.     Near  the  cardiac  orifice,  and 
in  the  small  curvature,  where  the  softening'and  diminished  con- 
sistence were  least  evident,  the  mucous  membrane  offered  four 
reddish  elevations,    firmer  than   itself,  about  a  line  thick  and 
rather  less  in  breadth.     No  peculiarity  observable  in  the  ves- 
sels which  were  under  the   softened  membrane.     The  lining 
membrane  of  the  small  intestine  was  of  a  pale-pink  hue,  and 
of  normal  thickness  and  consistence.     Some  small  ulcerations 
occupied  the  last  glandular  patches.     The  large  intestine  con- 
tained a  little  thin,  turbid,  reddish  fluid.    Its  mucous  membrane 
was  of  a  violet  red  color,  minutely  mamillated,  slightly  thick- 
ened, and  not  firmer  than  mucus.     In  the  ascending  and  trans- 
verse colon  there  vi^ere  three  ulcerations,  of  a  line  and  a  half  in 
diameter,  with  denudation  of  the  corresponding  muscular  coat. 
There  were  also  some  smaller  ones  in  the  middle  of  the  rec- 
tum, close  together,  and  lined  by  the  submucous  layer;  this 
was  opaque,  and  every  where  three  times  its  natural  thickness. 
The  liver  was  rather  voluminous,  pale,  adipous,  and  extending 
below  the  ribs.     Bile  of  the   gall-bladder,  moderately  thick, 
in  color  like  the  juice  of  preserved  prunes.     Spleen,  of  ordi- 
nary dimensions,  partially  invested  by  a  thick  false  membrane, 
containing  much  tuberculous  matter  ;  it   presented  internally 
about  sixty  granulations  of  the  same  nature,  surrounded  by 
the  healthy  parenchyma.     The  mesocaecum  and  small  omen- 
tum offered  on  their  surface  some  small  tuberculous  patches. 
The  other  viscera  were  healthy. 


Chap.  5.]    SOFTENING,  &LC.  OF  MUCOUS  MEMBRANE.  261 

321.  This  observation  is  interesting  in  many  respects.  In 
the  first  place,  the  simple  recital  of  the  facts  proves  that  the 
affection  of  the  lungs  and  that  of  the  stomach  commenced 
simultaneously,  which  is  by  no  means  usual  ;  and  while  in  the 
majority  of  cases  in  which  this  complication  exists,  death  is 
most  frequently  to  be  attributed  to  the  lungs,  it  was  in  this 
instance  caused  rather  by  the  state  of  the  stomach,  than  by  any 
other  lesion.  From  the  great  preponderance  of  the  gastric 
symptoms,  it  would  have  been  easy  in  this  case,  as  we  have  al- 
ready stated,  to  have  overlooked  the  presence  of  phthisis.  The 
patient's  attention  was  wholly  directed  to  the  stomach,  and  it 
was  necessary  to  force  her,  by  repeated  questions,  to  speak  of 
the  state  of  her  chest.  The  progress  of  the  softening  was  not 
very  rapid,  and  yet  we  never  saw  such  intense  anxiety  and 
uneasiness,  or  so  energetic  an  expression  of  suffering.  The 
succession  of  the  symptoms  is  particularly  worthy  of  attention  ; 
their  little  intensity  at  first  when  the  lesion  of  the  mucous 
membrane  was  inconsiderable,  and  their  uninterrupted  pro- 
gress afterwards.  In  the  beginning  we  find  slight  epigastric 
pains,  nausea,  and  vomiting  excited  by  cough  ;  the  nausea  is 
then  permanent  ;  the  vomiting  occurs  in  the  intervals  of  the 
cough,  consists  of  bile,  and  daily  increases  in  frequency  and 
copiousness;  there  is  a  gradual  augmentation  of  pain  ;  in  short, 
the  symptoms  are  always  proportionate  to  the  morbid  changes 
taking  place. 

322.  The  diarrhoea,  so  suddenly  violent  towards  the  close 
of  hfe,  is  also  a  very  remarkable  fact.  It  was  accompanied 
by  acute  pains  throughout  the  abdomen,  and  indicated  without 
doubt  the  commencement  of  one  of  those  severe  cases  of  en- 
teritis so  frequently  developed  in  the  last  stage  of  phthisis 
(264),  and  which  so  rapidly  produce  the  softening  of  the  mu- 
cous membrane  of  the  large  intestine.     Let  us  also  remark, 


262  SYMPTOMS.  —  STOMACH  ;  [Part  II, 

that  this  softening  corresponded  to  a  considerable  thickening 
of  the  submucous  layer,  which  retained  its  whiteness,  although 
we  cannot  but  consider  its  increased  thickness  as  the  result  of 
acute  inflammation  (135). 

323.  The  state  of  the  lung  and  pleura  of  the  right  side 
merit  attention.  The  former,  on  account  of  the  excavation  in 
the  upper  lobe,  which  offered  the  very  rare  example  of  a 
tuberculous  cavity  of  a  certain  size,  immediately  surrounded  by 
almost  healthy  parenchyma,  or  which  was  but  a  little  harden- 
ed ;  the  pleura,  on  account  of  the  false  membrane  on  its  sur- 
face, and  its  tubercular  transformation  ;  a  fact  we  have  never 
observed  except  when  tubercles  existed  in  the  lungs. 

324.  The  pleurisy  which  gave  rise  to  the  membranous 
exudation  came  on  only  a  month  before  death,  that  is,  when 
there  were  already  tubercles  in  the  summit  of  both  lungs,  and 
more  especially  of  the  right  ;  we  cannot,  therefore,  attribute 
their  development  to  this  inflammation.  We  cannot,  like- 
wise, suppose  the  pleurisy  to  have  been  the  cause  of  the 
tubercles  situated  immediately  under  the  pleura,  since  these 
were  equally  present  on  the  left  side,  where  the  lung  was  free 
from  all  adhesions,  and  the  pleura  natural. 

325.  Lastly,  the  tuberculous  matter  developed  in  the  false 
membranes  covering  the  right  pleura  and  spleen,  in  the  sub- 
stance of  the  latter,  and  on  the  peritoneal  surface,  was  every 
where  unsoftened,  in  the  same  stage  of  development;  this 
seems  to  require,  as  we  have  already  remarked  (210),  the 
presence  of  one  and  the  same  cause  simultaneously  acting 
upon  different  organs. 


Chap.  5.]    INFLAMMATION    OF    ITS    ANTERIOR    FACE.  263 


ARTICLE    IT. 

SYMPTOMS   OF    INFLAMMATION    OF   THE    MUCOUS  MEMBRANE  OF    THE 
ANTERIOR  FACE  OF  THE  STOMACH. 

326.  The  eight  individuals  in  whom  we  have  observed  this 
morbid  condition  experienced  during  a  variable  space  of  time, 
anorexia,  pains,  heat  in  the  epigastrium,  occasional  nausea  ; 
some  few  had  vomitings.  Only  one  was  exempt  from  pain, 
and  in  this  instance  phthisis  had  lasted  five  years,  and  the  ap- 
petite had  ceased  com.pletely  a  few  days  only  before  death. 

323.  These  symptoms  of  an  affection  of  the  mucous  mem- 
brane of  the  stomach  were  not  all  present  at  the  same  time. 
Anorexia  most  frequently  was  first  observed,  and  this  was  after 
a  time  accompanied  by  pain  in  the  epigastrium.  Pressure  in 
this  region  increased  this  pain,  and  there  was  often  a  burning 
sensation,  with  more  or  less  long  and  complete  remissions,  and 
a  feeling  of  suffocation  was  caused  by  the  lightest  food.  Nausea 
was  the  last  in  its  appearance,  very  variable  in  frequency  and 
duration,  and  sometimes  solicited  by  the  cough.  Vomiting 
only  occurred  in  two  instances,  in  one  of  these  the  ejected 
matter  was  bilious,  in  the  other  white  and  insipid.  In  every 
instance  there  was  fulness  in  the  epigastric  region,  produced 
by  the  hver  descending  below  the  ribs;  a  fact  which  has 
more  than  once  made  us  suspect  that  the  gastric  symptoms 
were  caused  by  inflammation  of  the  anterior  surface  of  the 
stomach. 

328.  The  symptoms  were  of  shorter  duration  than  when 
the  membrane  was  thinned  and  softened  ;  they  were  gene- 
rally present  froraone  to  three  months.     The  progress  of  the 


264  SYMPTOMS.  —  STOMACH  ;      [Part  II, 

affection  was  chronic,  though  the  pain  and  other  morbid  phe- 
nomena were  occasionally  very  urgent.  The  following  is  one 
of  the  most  interesting  examples  that  we  have  collected. 


EIGHTEENTH     OBSERVATION. 

An  unmarried  female,  set.  26,  of  a  strong  constitution,  of 
nervous  temperament,  and  who  had  suffered  constantly  from 
colds  during  the  last  five  years,  entered  the  hospital  of  La 
Charité,  January  20th,  1823.  During  the  first  two  years  and 
a  half,  none  of  her  symptoms  had  been  urgent.  After  this, 
there  was  an  increase  of  cough  and  expectoration,  and  for  five 
months  a  constant  spitting  of  blood,  notwithstanding  repeated 
bleedings  and  the  application  of  leeches.  There  was  some 
slight  improvement  in  the  general  symptoms  the  two  following 
years  ;  she  almost  completely  regained  her  strength  and  flesh  ; 
the  catamenia,  which  had  been  suppressed  during  eighteen 
months,  returned  at  their  usual  intervals  ;  in  short,  she  suffer- 
ed from  nothing  but  a  slight  cough  and  some  dyspnoea,  when 
in  November,  1822,  after  dancing,  she  was  attacked  during 
the  night  with  violent  rigors,  followed  by  heat  and  perspira- 
tion, accompanied  with  pains  in  the  right  side  of  the  chest, 
and  increased  cough  and  dyspnœa.  From  that  moment,  the 
shiverings  returned  every  evening,  the  pain  persisted,  and  on 
the  sixth  day  she  was  attacked  by  an  haemoptysis,  which  con- 
tinued, though  gradually  diminishing  in  intensity  up  to  the 
period  of  the  patient's  admission  into  the  hospital. 

January  9th.  Oppressive  headache  ;  considerable  debility  ; 
dyspnoea  with  shooting  pains  between  the  shoulders  ;  cough, 
frequent   at  night  ;    expectoration,    greenish,   streaked  with 


Chap.  5.]    INFLAMMATION    OF    ANTERIOR    FACE,    hc.  265 

blood,  scanty  ;  this  was  mingled  with  a  clear,  frothy,  and 
more  copious  fluid  ;  a  mucous  râle  posteriorly  on  the  r'ght 
side;  every  where  else,  r  spiration  was  healthy;  no  reso- 
nance of  voice  nor  pectoriloquy  ;  tongue,  mtural  ;  thirst, 
urgent;  anorexia;  nausea  from  cough  ;  epigastrium,  sensible 
to  pressure  ;  constipation. 

(Pectoral  ptisan  ;  pectoral  mixture  with  ammonia  ;  two 
small  rice  creams). 

January  22d.  Sputa  nummulated  (pelotonnés),  united  by  a 
clear  mucus,  without  any  trace  of  blood  ;  the  patient  com- 
plained of  acute  pain  in  the  right  side  ;  leeches  were  applied 
with  decided  relief.  On  the  next  day  pains  in  the  epigas- 
trium, with  nausea  in  the  intervals  of  the  cough.  From  this 
period  until  death,  which  took  place  on  the  17th  of  May,  the 
following  symptoms  were  observed. 

On  the  27th  of  January,  there  was  a  fresh  pain  in  the  right 
shoulder,  near  which  a  crepitous  rale  mingled  with  a  gurgling 
could  be  heard.  On  the  29th,  the  pain  had  increased,  the 
respiration  was  much  more  embarrassed,  the  cough  frequent, 
and  the  expectoration  clear  with  thick  spots  of  florid  blood  ;  a 
fine  crepitation  was  heard  over  the  whole  of  the  right  side  of 
the  chest.  Pulse,  very  rapid,  small  and  weak.  Eight  ounces 
of  blood  were  taken  with  prompt  relief  February  5th. 
Another  attack  of  pain,  slight  crepitation  under  the  right 
mamma  ;  this  also  readily  yielded  to  an  application  of  leeches. 
Subsequently  the  pain,  dyspnoea  and  crepitation,  with  occa- 
sional yellowish  and  rather  viscous  sputa,  were  renewed 
from  time  to  time,  and  combated  by  the  same  means,  varied 
according  to  the  strength  of  the  patient.  On  the  5th  of  May, 
there  was  evident  pectoriloquy  between  the  scapula  and  spinal 
column  on  both  sides,  with  dulness  on  percussion  under  the 
right  clavicle,  where  there  v/as  some  fine  crepitation.  On  the 
J   2 


266  SYMPTOMS.  —  GASTRIC  ;  [Part  II, 

11th,  there  was  slight  haemoptysis,  and  the  expectoration 
assumed  a  dirty  grey  color,  which  it  retained  to  the  last.  The 
anorexia  and  nausea  continued  some  days,  after  which  the  ap- 
petite improved,  so  that  she  ate  one  fourth  of  the  full  allow- 
ance, with  only  a  slight  feeling  of  oppression  after  every  meal. 
In  the  commencement  of  JVJarch,  the  anorexia,  with  sharp 
pains  in  the  epigastrium,  returned.  On  the  15th  and  16th, 
there  was  almost  constant  nausea,  with  small  bilious  vomitings 
and  sense  of  heat  in  the  epigastric  region.  The  loss  of  appe- 
tite continued,  the  nausea  gradually  ceased,  leaving  headache, 
general  lassitude,  and  some  bilious  vomitings.  During  the 
month  of  April  the  same  symptoms  were  observed  ;  the  epi- 
gastric pains  were  very  severe,  and  the  vomiting  of  bile  oc- 
curred at  intervals.  On  the  second  of  May,  increased  anxiety 
and  uneasiness,  with  tenderness  of  the  abdomen  ;  constant 
epigastric  pain,  increased  by  the  slightest  pressure,  cough  or 
movement  of  the  body. 

The  tongue,  which  had  hitherto  been  natural  in  color,  be- 
came very  red,  and  covered  with  small,  whitish,  membranous 
patches,  easily  removed.  These  appeared  and  disappeared 
several  times,  and  the  pain  in  the  region  of  the  stomach  after 
a  slight  diminution  returned  with  great  intensity  a  few  days 
before  death.  Diarrhœa  came  on  during  the  last  fortnight  ; 
the  pulse  was  constantly  accelerated  ;  the  heat  of  the  skin 
increased  towards  the  evening,  with  frequent  night  perspira- 
tions ;  the  rigors  were  much  more  rare. 

Opening  of  the  corpse  twenty-six  hours  after  death. 

Exterior.  —  Extreme  emaciation.  Nothing  else  remark- 
able. 

Head.  —  Adhesion  between  the  arachnoid  and  dura  mater, 
near  the  longitudinal  fissure  and  in  other  points  near  it,  by  means 


Chap.   5.]    LIVER    INFLUENCES    THIS     INFLAMMATION.  267 

of  some  white,  opaque  granulations  attached  to  the  arachnoid, 
which  was  more  or  less  thickened  and  opaque  in  the  corres- 
ponding portions  ;  the  sub-arachnoidean  infiltration,  rather 
copious  ;  cerebral  substance,  softer  than  natural  ;  three  spoons- 
ful of  fluid  in  the  left  lateral  ventricle,  rather  less  in  the  right  ; 
half  a  spoonful  of  similar  fluid  in  the  ventricle  of  the  septum 
lucidum,  which  was  itself  firm  and  resisting. 

Neck.  —  Left  cervical  glands,  voluminous,  tuberculated, 
but  not  softened  ;  similar  state  of  the  bronchial  glands  ;  larynx 
and  epiglottis,  natural;  trachea,  of  a  pale  pink  color,  without 
ulceration. 

Thorax.  —  Some  slight  cellular  adhesions  at  the  summit 
of  both  lungs.  Externally  there  were  whitish  and  slightly 
pink-colored  elevations  formed  by  the  tuberculous  matter.  In 
the  upper  lobe  of  the  right  lung  there  were  two  cavities  com- 
municating with  the  bronchia,  and  a  certain  number  of  tuber- 
cles surrounded  by  the  firm,  granulated,  hepatized  lung,  im- 
permeable to  the  air,  of  a  red  color  anteriorly,  and  a  yellowish 
grey  posteriorly.  In  the  lower  lobe  there  were  only  a  few 
tuberculous  granulations.  In  the  upper  part  of  the  left  lung 
there  were  some  small  excavations,  and  some  semi-opaque, 
grey  granulations,  surrounded  by  a  grey,  semi-transparent 
substance  into  which  this  lobe  was  almost  entirely  changed. 
The  lower  contained  only  a  small  number  of  granulations,  and 
was  slightly  congested  at  its  base.  There  were  four  ounces 
of  serosity  in  the  pericardium  ;  the  heart  was  small  but  healthy  ; 
the  aorta  and  pulmonary  artery,  sound. 

Abdomen. -—The  liver  extended  four  inches  below  the 
false  ribs,  was  enlarged,  adipous,  of  a  tawny  color,  spotted 
with  red,  and  of  moderate  density.  The  gall-bladder  contain- 
ed a  dense  black,  stringy  bile  ;  the  stomach  descended  below 
the  crest  of  the   ilium,  was  voluminous,  much  elongated,  and 


268  SYMPTOMS.  —  GASTRIC  ;  [Pavt  II, 

partially  overlapped  by  the  liver;  its  lining  membrane  was 
covered  by  a  thick  viscous  mucus,  much  more  abundant  over 
its  anterior  surface  than  elsewhere.  In  the  former  part  it  was 
of  a  bright  red,  evidently'thickened  and  rather  softened  ;  in  the 
remainder  of  its  surface  it  was  of  a  pale  red,  and  was  of  a  healthy 
consistence  and  thickness.  Duodenum,  healthy.  The  mu- 
cous membrane  of  the  small  intestine  was  slightly  greyish  colored 
and  easily  torn,  with  here  and  there  vascular  aborisations,  and 
presented  seven  small  dark  ulcerations,  generally  distributed, 
of  two  lines  in  diameter,  with  wide  intervals  between  them. 
The  lining  membrane  of  the  large  intestine  was  greyish  or 
blackish,  and  every  where  softened,  with  twelve  small  ulcera- 
tions ill  the  ascending  colon,  and  three  in  the  rectum  imme- 
diately above  the  sphincter  ani  ;  the  mucous  membrane  was 
slightly  detached  on  their  edges,  and  the  corresponding  sub- 
mucous layer  greyish-colored  and  a  little  thickened.  The 
mesenteric  glands  were  healthy,  but  around  the  biliary 
vessels  there  were  numerous  tuberculated  lymphatic  glands. 
Spleen,  small,  with  four  tubercles,  of  the  size  of  a  small  nut, 
in  the  middle  of  healthy  texture. 

329.  Let  us  reflect  a  moment  on  the  facts  of  this  observa- 
tion. The  volume  of  the  stomach  was  very  considerable,  it 
extended  low  down,  and  was  partly  covered  by  the  liver  ; 
the  mucous  membrane  lining  the  anterior  surface  was  of  a 
bright  red  color,  thickened,  and  a  little  softened,  most  evi- 
dently inflamed  ;  the  inflammation  was  almost  limited  to  the 
portion  overlapped  by  the  liver,  which  renders  the  influence 
of  this  organ  on  its  development  very  probable.  The  ano- 
rexia, epigastric  pain,  nausea  and  bilious  vomitings  were  in 
unison  with  the  gastric  lesion,  and  from  the  urgency  of  the 
former,  we  might  have  anticipated  the  more  serious  alteration 


Chap.   5.]    LIVER    INFLUENCES    THIS     INFLAMMATION.  269 

of  softening  with  diminished  tliickness.  Though  chronic  in 
their  progress,  the  symptoms  daily  acqulied  greater  intensity. 
Thus  this  lorm  of  gastritis,  which  prevailed  in  seven  eighths  of 
our  cases,  gave  rise  to  characteristic  symptoms,  only  varying 
from  the  mere  acut  form  by  being  less  urgent,  and  by  the  ab- 
sence of  vomiting  in  most  cases.  This  fact  confirms  what  we 
have  advanced  in  the  preceding  article  ;  namely,  that  the 
stomach,  in  common  with  the  other  organs,  reveals  its  morbid 
alterations  by  pain  and  the  greater  or  less  disturbance  of  its 
functions. 

We  shall  shortly  specially  consider  the  state  of  the  tongue, 
but  we  may  here  remark,  that  in  the  last  two  instances  it  re- 
tained its  natural  appearance  ;  that  it  was  even  pale  up  to  the 
moment  when  it  was  covered  with  an  apthous  exudation,  a 
period  long  subsequent  to  the  invasion  of  the  gastritis. 

330.  The  development  of  tuberculous  matter  in  the  lym- 
phatic glands  is  worthy  of  notice.  The  mucous  membrane 
of  the  trachea  was  of  a  very  pale  pink  color,  less  so  than  what 
we  usually  observe  after  a  variety  of  other  diseases  ;  it  was 
neither  softened  nor  thickened  ;  it  might  have  been  considered 
perfectly  healthy,  and  consequently  we  have  no  reason  to  attri- 
bute to  it  the  state  of  the  cervical  glands.  It  will,  however, 
perhaps  be  thought,  that  the  state  of  the  glands  surrounding 
the  biliary  vessels,  might  be  explained  by  the  inflammation  of 
the  gastric  mucous  membrane.  To  this  we  would  reply,  that 
if  some  of  the  lymphatics  of  the  stomach  traverse  the  glands 
in  question,  it  can  only  be  after  passing  through  those  situated 
on  the  small  curvature,  and  if  the  inflammation  of  the  mucous 
membrane  was  not  sufficient  to  transform  these  latter  into 
tuberculous  matter,  we  cannot  suppose  it  capable  of  affecting 
the  more  distant.  Let  us  add  also,  that  we  have  only  seen 
the  tubercular   transformation  of  the  glands   surrounding  the 


2T0  SYMPTOMS.  —  GASTRIC  ;  [Part  II. 

biliary  ducts,  three  times,  and  tliat  we  have  never  seen  the 
same  alteration  in  the  glands  occupying  the  small  or  great  curve 
of  the  stomach,  although  a  somewhat  chronic  inflammation 
of  the  gastric  raucous  membrane  was  very  frequent. 

331.  We  shall  be  very  brief  on  the  morbid  alterations  in 
the  lungs,  only  remarking,  that  the  frequent  recurrence  of  in- 
flammation on  the  right  side  confirms  what  we  have  advanced 
(286)  relative  to  the  harmlessness  of  pneumonia  in  phthisis,  and 
that  tubercles  may  be  regarded,  in  this  respect,  as  foreign 
bodies,  the  influence  of  which  is  almost  always  less  injurious 
that  of  internal  causes. 


ARTICLE   III. 

SYMPTOMS  OBSERVED  WHEN  THE  MUCOUS  MEMBRANE  OF  THE  STOMACH 
IS  RED  AND  SOFTENED  IN  THE  GREAT  CUL-DE-SAC. 

332.  Whether  this  state  of  the  lining  membrane  was  alone 
present  or  accompanied  with  small  ulcerations,  or  a  niamil- 
lated  state  of  the  mucous  membrane,  we  could  seldom  detect 
any  symptom  which  might  be  considered  characteristic. 
There  had,  in  some  cases,  been  diminished  appetite  long  be- 
fore death,  but  this,  with  some  exceptions,  seemed  to  coin- 
cide with  the  progress  of  the  principal  affection,  and  was  also 
present  when  the  gastric  mucous  membrane  was  sound.  In 
the  majority  of  cases  there  was  only  complete  anorexia  from 
ten  to  twenty  days  before  death.  In  two  instances,  or  one 
ninth,  towards  the  close  of  life,  there  were  nausea  and  epigas- 
tric pains.  This  absence  of  symptoms  attending  an  alteration 
which  is  usually  very  serious,  and  which  presents  the  char- 
acteristics of  acute  gastritis,  has  made  us  suppose  that  in  the 
majority  of  cases  it  came  on  very  shortly  before  death. 


Chap.  5.]    SOFTENING    AND    REDNESS    OF    CUL-DE-SAC.       271 

333.  The  following  is  one  of  the  two  cases  we  have  men- 
tioned, in  which  the  gastric  symptoms  had  the  longest  dura- 
tion and  greatest  intensity. 


NINETEENTH    OBSERVATION. 

An  unmarried  woman,  set.  48,  tall,  of  a  strong  constitution, 
and  not  having  menstruated  the  last  ten  years,  entered  the 
hospital  September  22d,  1822.  She  said  she  had  been  ill  nine 
months,  was  never  subject  to  cold,  and  had  not  had  pneu- 
monia ;  at  the  commencement,  cough,  expectoration,  dyspnœa 
and  night  sweats  ;  these  symptoms  persisted,  gradually  in- 
creased, and  the  perspirations  had  become  copious.  During' 
the  fifth  month  she  was  attacked  with  haemoptysis,  which 
lasted  two  days,  with  pain  in  the  right  side  ;  the  latter  has 
since  continued,  though  less  soon  after  it  commenced  ;  she  is 
obliged  to  lie  on  the  left  side.  Rigors  were  rare  ;  diminution 
of  appetite  since  the  invasion  of  cough,  and  for  four  months 
the  patient  has  only  taken  a  small  quantity  of  boiled  meat 
with  bread  ;  thirst,  urgent  ;  emaciation  from  the  first. 
.  September  3d.  General  headache  ;  subject  the  last  six 
months  to  giddiness  on  assuming  the  vertical  position  ;  nose 
and  lips  livid  ;  lies  with  the  head  raised  ;  respiration,  rather 
thoracic  and  accelerated  ;  cough,  moderately  frequent  ;  sputa, 
scanty,  clear,  spumous,  or  greenish,  and  with  white  streaks. 
On  the  right  side,  anteriorly,  and  especially  exteriorly  to  the 
mamma,  the  chest  was  dull  on  percussion  ;  there  was  no  pain, 
but  almost  every  where  gurgling  and  very  coarse  crepitation. 
Under  the  clavicle  there  were  tracheal  respiration  and  indis- 
tinct pectoriloquy.     On  the   left,   nothing   peculiar,  either  by 


272  SYMPTOMS.  —  GASTRIC  ;  [Part  11, 

auscultation  or  percussion.  Pulse,  frequent,  unequal,  irregu- 
lar, and  sometimes  intermittent  ;  the  action  of  the  heart  was 
"sensible  in  every  part  of  chest,  and  accompanied  with  pretty 
strong  impulse  in  the  precordial  region,  especially  under  the 
sternum;  mouth,  clammy,  with  bitter  taste;  thirst,  urgent  ; 
anorexia  ;  tongue,  rather  red  in  the  centre  ;  pain  in  the  epigas- 
trium for  some  hours  ;  nausea,  rather  frequent  immediately 
after,  and  in  the  intervals  of  cough  ;  bowels,  costive  ;  ab- 
domen, rather  tympanitic. 

(Compound  decoction  of  inula  with  nitre  ;  gum  potion, 
with  thirty  drops  of  tinct.  digitalis  ;  twelve  leeches  to  the 
anus). 

From  this  moment  until  the  first  of  October  (day  of  her 
death),  continuance  of  the  same  symptoms  ;  the  anorexia, 
nausea,  epigastric  pains  were  more  or  less  urgent  ;  no  vomit- 
ting.  A  small  quantity  of  soup  did  not  appear  to  increase 
the  uneasiness  ;  the  tongue  continued  red  in  the  centre  ;  there 
was  slight  diarrhœa,  with  some  pains  in  the  right  side,  in  the 
direction  of  the  colon.  The  pulse  was  less  irregular  twenty- 
four  hours  after  the  api)lication  of  the  leeches,  but  afterwards 
its  Irregularity  daily  increased.  The  lower  extremities  be- 
came infiltrated  ;  perspirations  were  copious,  with  occasional 
rigors. 

No  sensible  change  of  expectoration.  The  dyspnœa  rapidly 
increased,  at  times  requiring  a  sitting  posture;  the  pain  under 
the  right  mamma  continued  more  or  less  acute  to  the  last  ; 
death  took  place  after  an  agony  of  some  hours. 

Opening  of  the  corpse  twenty-eight  hours  after  death. 

ExTERiou.  —  Slight   infiltration  of  the   lower   extremities. 
Redness  of  the  ride  side  of  the  face  where  the  head  rested. 
Head.  —  Some  nearly  fluid  sub-arachnoidean   infiltration. 


Chap.   5.]    SOFTENING    AND    REDNESS    OF    CUL-DE-SAC.       273 

A  spoonful  of  serum  in  each  lateral  ventricle;  the  rest  of  the 
brain  was  entirely  healthy. 

Thokax.  —  Dense  adhesions  at  the  summit  and  base  of  the 
right  lung,  by  means  of  a  firm,  thick,  membranous  effusion. 
Between  these  points,  the  false  membrane  formed  a  kind  of 
sack,  traversed  by  filaments  enclosing  in  their  intervals  a  small 
quantity  of  clear  reddish  fluid.  A  large  rugged  excavation 
occupied  the  summit  of  the  right  lung,  lined  by  a  double  false 
membrane  ;  its  firmest  layer  was  in  contact  with  the  pulmon- 
ary structure,  which  was  either  healthy,  or  more  or  less 
severely  altered;  a  communication  existed  between  this  cavity, 
the  bronchia  and  numerous  small  cavities.  The  lower  lobe 
was  congested.  No  adhesion  of  the  left  lung  ;  it  contained  a 
few  crude  tubercles,  and  a  small  quantity  of  the  grey,  semi- 
transparent  matter  in  its  upper  lobe.  The  heart  and  pericar- 
dium were  invested  by  an  undulated  false  membrane  of  toler- 
able consistence,  a  line  or  more  in  thickness,  thinner  upon  the 
auricles  than  upon  the  ventricles,  and  bathed  by  a  small  quan- 
tity of  clear  reddish  fluid.  Parietes  of  the  left  ventricle  rather 
thicker  than  natural  ;  those  of  the  auricles  were,  on  the  con- 
trary, thinner  than  usual.  Lining  membrane  of  the  aorta  and 
its  branches  of  a  bright  red  color,  without  any  change  of  thick- 
ness or  consistence. 

Abdomen.  —  Two  quarts  of  clear  fluid  in  the  peritoneal 
cavity  ;  stomach,  voluminous;  lining  membrane,  thick,  very 
soft,  of  a  violet  red  in  the  large  extremity  ;  of  a  greyish  color, 
mamillated,  and  of  increased  thickness  and  consistence  in  the 
remainder  of  its  extent.  The  mucous  membrane  of  the  small 
intestine  was  of  twice  its  usual  thickness  in  the  upper  three 
fifths  ;  color  and  consistence,  every  where  normal  ;  there 
were  three  very  small  ulcerations  near  the  ileo-caecal  valve. 
That  of  the  large  intestine  was  much  softened  throughout  its 
K  2 


274  SYMPTOMS.  —  GASTRIC  ;  [Part  II, 

whole  length  ;  of  a  pale  pink  color  in  the  descending  colon 
and  rectum,  with  numerous  small  ulcerations,  diminishing  in 
number  from  above  downwards.  Mesenteric  glands,  healthy  ; 
liver,  voluminous,  congested,  of  a  greyish-yellow  color,  spotted 
with  bright  red  ;  bile  in  the  gall-bladder,  thin  and  light  color- 
ed. Left  kidney,  of  twice  its  usual  volume  ;  the  right,  at 
least  four  times  as  large  as  common,  with  an  uneven  lobulated 
surface,  almost  wholly  consisting  of  a  membranous  sac,  filled 
by  a  clear,  dark-colored  fluid  like  urine,  and  intercepted  by  a 
transverse  septum,  pierced  in  its  centre.  There  were  no 
traces  of  the  renal  structure  except  on  the  convex  edge, 
where  there  was  a  layer  from  two  to  three  lines  thick.  On  the 
neck  of  the  uterus  there  was  a  soft  vesicular  polypus,  of  the  form 
and  size  of  the  uvula;  the  other  viscera  appeared  healthy. 

334.  The  lining  membrane  of  the  stomach  was  here  the 
seat  of  two  very  distinct  alterations  ;  the  one,  consisting  of 
redness,  thickening  and  softening  of  the  portion  covering  the 
large  extremity,  was  recent  ;  the  other  (the  mamillated  state) 
was  the  result  of  a  chronic  affection.  To  the  latter  we  might 
be  inclined  to  attribute  the  anorexia  which  was  present  at  the 
early  part  of  the  disease  ;  but  we  shall  soon  find  (340)  that 
we  have  no  satisfactory  reasons  for  doing  so.  As  to  the  epi- 
gastric pains  and  nausea,  which  were  experienced  about  a 
month  before  death,  they  may  be  compared  with  what  we 
have  observed  in  the  cases  of  the  preceding  sections,  and 
evidently  indicate  a  more  recent  affection  than  the  mamillated 
state,  which,  in  fact,  has  never  presented  to  us  the  same  symp- 
toms ;  they  must,  therefore,  be  referred  to  the  inflammation  of 
the  mucous  membrane  of  the  great  cul-de-sac. 

335.  It  is  very  remarkable,  moreover,  that  notwithstanding 
the  co-existence  of  so  many  serious  lesions,  the  one  we  are 


Chap.   5.]    FROM    ULCERS    OF    THE    MUCOUS    MEMBRANE.     275 

now  considering  gave  rise  to  very  distinct  symptoms,  doubtless 
nearly  as  they  would  have  been  in  a  case  of  simple  gastritis, 
and  that  the  same  remark  will  equally  apply  to  the  pleurisy, 
phthisis,  and  pericarditis.  The  fever  at  the  commencement 
may  be  ascribed  to  the  development  of  the  pulmonary  tuber- 
cles, for  all  complications  were  absent  until  some  time  after- 
wards ;  and,  moreover,  we  shall  relate  cases  of  simple  phthisis 
(Obs.  27,  28,  29),  in  which  fever  came  on  at  the  same 
period,  and  with  greater  intensity. 


A  RT I  C  L  E     I  V . 

SYMPTOMS   OF    SIMPLE    ULCERATION    OF   THE    GASTRIC    MUCOUS  MEM- 
BRANE. 

336.  Of  this  condition,  as  we  have  already  said  (96),  we 
have  only  met  two  examples.  In  one,  where  a  single  ulcer- 
ation of  about  two  inches  in  surface  existed  (Obs.  38),  the 
patient  experienced  during  the  last  three  months  of  life  a  pain 
in  the  epigastrium,  increased  after  meals  ;  during  the  same 
period  there  was  diminished  appetite,  with  slow  and  painful 
digestions  ;  the  other  instance  we  shall  now  detail. 


TWENTIETH    OBSERVATION. 

A  GIRL,  set.  19,  of  a  nervous  temperament,  and  weak  and 
delicate  constitution,  naturally  thin,  not  having  menstruated, 
and  subject  to  shortness  of  breath  from  her  infancy,  was  ad- 
mitted into  the  hospital  of  La  Charité,  February  24th,  1824. 
She  had  been  ill  three  years.     Her  illness  had  commenced 


276  SYMPTOMS.  —  GASTRIC  ;  [Part  II, 

with  a  violent  hasmoptysis,  recurring  two  days  afterwards,  and 
treated  by  bleeding.  This  haemorrhage  subsequently  reap- 
peared every  two  or  three  months,  more  frequently  during  the 
winter  than  summer  ;  the  last  attack  was  about  a  month  be- 
fore entrance.  It  was  always  accompanied  with  efforts  of 
vomiting,  and  the  patient  believed  that  the  blood  came  from 
the  stomach.  Cough  and  expectoration  commenced  with  the 
haemoptysis,  and  had  since  continued  ;  her  habitual  dyspnœa 
was  much  aggravated,  and  she  had  been  annoyed  occasion- 
ally by  pains  in  her  chest.  Nausea  and  vomiting,  often  ac- 
companied the  paroxysms  of  cough,  and  diarrhœa  with  colic, 
lasting  a  few  days  or  weeks,  had  not  been  infrequent  from  the 
beginning  ;  the  appetite  had  always  been  pretty  good.  Dur- 
ing the  year  before  entrance  she  was  very  subject  to  rigors, 
and  for  fifteen  days  she  had  had  heat  in  the  evenings,  and  night 
perspirations  ;  no  thirst.  The  patient  had  continued  to  grow 
taller,  and  assured  me  that  she  had  lost  but  little  flesh. 

February  25th.  Face  and  the  rest  of  the  surface  of  the 
body,  pale  ;  little  appetite  ;  tongue,  a  little  whitish  ;  epigastri- 
um, not  painful  ;  stools,  not  painful,  but  rare  ;  breathing,  rather 
accelerated  ;  slight  oppression  ;  cough,  often  dry,  most  trouble- 
some at  night;  it  sometimes  caused  nausea  and  vomiting. 
Sputa,  thick,  greenish,  scanty,  lying  in  a  limpid  fluid  like 
saliva.  Percussion  of  the  chest,  every  where  clear.  For 
about  four  inches  under  the  right  clavicle  there  was  a  coarse 
and  copious  crepitation  ;  and  in  the  corresponding  point  pos- 
teriorly, there  were  tracheal  respiration  and  imperfect  pecto- 
riloquy ;  on  the  left  side  this  was  quite  distinct.  Pulse, 
rather  quick  ;  heat,  moderate. 

(Infusion  of  violets  ;  to  sit  over  the  vapor  of  hot  water  ;  six 
leeches  to  labia;  a  fourth  of  house  allowance). 

The    progress    of  the  disease    was   slow,   but    constant. 


Chap.  5.]    FROM   ULCERS    OF    THE    MUCOUS    MEMBRANE.     277 

From  the  beginning  of  March  the  appetite  greatly  diminish- 
ed ;  there  was  a  sense  of  weight  in  the  epigastrium  after  food, 
with  almost  constant  nausea  and  vomitings,  either  after  or  in 
the  intervals  of  the  cough.  A  small  quantity  of  bile  was 
sometimes  mingled  with  the  contents  of  the  stomach  ;  the 
mouth  was  clammy,  and  had  a  bitter  taste  during  the  whole 
of  this  month  ;  the  tongue  was  whitish  in  the  centre,  and  a 
little  red  on  the  edges.  In  April,  the  symptoms  were  more 
urgent;  the  mildest  drinks  caused  oppression  in  the  epigas- 
trium, and  were  sometimes  vomited  ;  very  rarely  pure  bile 
was  ejected  ;  nausea  was  constant  ;  appetite,  almost  gone  ; 
expression  depressed  ;  temper,  irritable,  with  frequent  anx- 
iety ;  the  thirst  became  very  urgent,  without  any  change  in 
the  appearance  of  the  tongue  ;  she  never  complained  of  epi- 
gastric pains.  The  same  symptoms  continued  until  death, 
which  occurred  on  the  I2th  of  May. 

The  stools  became  soft  towards  the  end  of  March  ;  they 
were  fluid  at  the  beginning  of  April,  and  preserved  the  same 
character,  though  never  numerous,  three  or  four  a  day  to  the 
last  ;  they  were  accompanied  with  very  little  colic  pain. 

The  dyspnœa  rapidly  increased  ;  the  cough  was  always 
more  urgent  during  the  day  than  at  night.  From  April  the 
sputa  were  nummulated,  with  a  ragged,  flocculent  appearance, 
and  after  the  1st  of  May,  greenish,  flat  and  purulent.  On  per- 
cussion the  chest  was  very  dull  anteriorly  and  on  the  left,  to- 
wards the  end  of  April.  From  the  18th  of  March,  under  both 
clavicles  and  in  the  corresponding  region  posteriorly,  there  were 
tracheal  respiration  and  pectoriloquy.  Under  the  right  clavi- 
cle, occupying  a  considerable  extent,  there  was  a  very  coarse 
crepitation,  with  occasional  gurgling.  At  the  end  of  April, 
this  double  râle  was  evident  on  the  left  side,  first  anteriorly, 
then  posteriorly,    through  almost  the    whole  extent   of  the 


278  SYMPTOMS.  —  GASTRIC  ;  [Part  II, 

chest  ;  this  continued  until  death.  There  were  from  time  to 
time  pains  in  the  left  shoulder,  right  side  of  the  chest,  or  in  the 
iarynx.  Heat  of  surface,  much  elevated  ;  copious  night  sweats  ; 
rigors  rare,  and  from  the  end  of  April  the  pulse  was  rapid. 

There  was  a  variably  intense  but  constant  headache  ;  and 
from  the  20th  to  the  30th  of  April  she  complained  of  contin- 
ual tendency  to  drowsiness.  These  symptoms  disappeared 
spontaneously.  Slight  delirium  during  the  last  twenty-four 
hours  ;  gradual  loss  of  strength  ;  and  she  was  wholly  con- 
fined to  her  bed  after  the  middle  of  April.  On  the  18th  of 
March  nine  leeches  were  applied  to  the  labia  ;  a  gum  potion, 
with  a  grain  of  opium,  was  almost  constantly  prescribed  ;  the 
diarrhœa,  when  severe,  was  treated  by  the  white  decoction 
and  diascordium  ;  the  food  was  limited  to  some  rice  creams, 
and  for  the  last  six  weeks  scarcely  any  thing  was  taken. 

Opening  of  the  corpse  thirty  hours  after  death. 

Exterior.  —  Extreme  emaciation  ;  no  œdema. 

Head.  —  A  very  small  quantity  of  fluid  in  the  lateral  ven- 
tricles ;  brain  and  membranes,  perfectly  healthy. 

Neck.  —  Larynx  and  epiglottis,  natural  ;  mucous  mem- 
brane of  trachea,  of  a  rather  bright  red  color  inferiorly,  of  good 
consistence. 

Thorax. — Summit  of  the  right  lung,  adherent  ;  theleft  per- 
fectly free  ;  both  lungs  voluminous,  of  a  light  pink  color,  be- 
coming deeper  posteriorly.  The  upper  lobe  of  the  left  lung 
was  indurated,  with  some  yellow-colored  elevations  on  its  sur- 
face, corresponding  to  small  tuberculous  excavations,  separated 
by  a  very  thin  layer  from  the  pleura  ;  the  whole  lobe  was 
converted  into  half  filled  tuberculous  cavities,  separated  by 
the  grey  semi-transparent  matter,  or  the  red,  granulated,  hep- 
atized  lung.     At  the  summit  there  was  a  middle-sized  exca- 


Chap.  5.]  FROM  ULCERS  OF  THE  MUCOUS  MEMBRANE.  279 

vation,  communicating  with  numerous,  very  much  dilated 
bronchial  ramifications.  The  lower  lobe  was  slightly  con- 
gested, easily  torn,  and  interspersed  with  tubercles.  In  the 
summit  of  the  right  lung  there  was  an  excavation  four  times 
as  large  as  that  of  the  left  ;  the  remainder  of  the  lobe  pre- 
sented a  mixture  of  grey  matter,  tubercles,  and  healthy  struc- 
ture. The  bronchia  were  red  and  not  thickened  ;  the  bron- 
chial glands  voluminous,  but  not  tuberculated  ;  heart  and 
aorta,  natural. 

Abdomen.  —  Stomach,  rather  smaller  than  usual,  containing 
a  little  yellowish  fluid.  Its  lining  membrane  was  white, 
smooth,  and  near  the  pylorus  covered  with  a  thick  mucus. 
With  the  exception  of  this  region,  and  a  small  portion  of  the 
great  cul-de-sac,  it  presented  from  seventy  to  eighty  ulcera- 
tions, from  one  to  two  lines  in  diameter.  Its  destruction  in 
the  corresponding  points  was  not  always  complete  ;  it  was 
sometimes  only  thinned,  so  that  the  thinning  was  in  bands  of 
two  or  three  lines  wide.  In  the  intervals  it  was  pale,  and  of 
normal  thickness  and  consistence.  The  mucous  membrane 
of  the  small  intestine  was  healthy.  That  of  the  caecum  was 
red,  much  softened  and  thickened  here  and  there.  In  the  colon 
it  was  only  rather  softer  than  natural.  No  alteration  of  the 
mesenteric  and  mesocolic  glands.  The  liver  was  pale,  rather 
soft,  of  usual  dimensions  ;  uterus,  one  inch  wide,  and  five 
lines  only  thick  ;  the  other  viscera  were  healthy. 

337.  In  the  majority  of  cases  where  the  mucous  membrane 
of  the  stomach  is  ulcerated,  it  is  more  or  less  thickened  or 
mamillated  in  the  intervals,  but  in  this  example  no  such  alter- 
ation was  observed  ;  the  ulcerations  seemed  artificially  pro- 
duced, and  had  they  not  been  present  we  might  have  said  the 
membrane  was  quite   healthy.     At  the  same  time  the  gastric 


280  SYMPTOMS.  —  GASTRIC  ;  [Part  II, 

symptoms  were  rather  severe,  and  there  could  be  no  doubt  of 
a  more  or  less  serious  lesion  of  the  mucous  membrane  ;  there 
was  no  epigastric  pain,  but  nausea  and  vomiting  were  present 
long  before  death,  continued  to  the  last,  and  notwithstanding 
its  slow  progress,  the  affection  was  always  plainly  marked. 

338.  The  healthy  condition  of  the  mucous  membrane  of 
the  small  intestine  must  not  escape  attention  ;  that  of  the 
colon  was  only  slightly  softened,  while  the  diarrhœa  had  per- 
sisted several  months.  It  is  probable  that,  under  these  cir- 
cumstances, it  depended  for  a  time  on  a  change  of  secretion 
jnot  caused  by  inflammation. 

339.  When  the  only  lesion  of  the  gastric  mucous  membrane 
was  the  mamillated  state,  we  have  not  been  able  to  detect 
any  symptoms  by  which  it  might  be  recognised.  In  some 
cases  the  appetite  was  diminished  from  the  commencement  ; 
in  others  from  the  middle  of  the  disease  ;  and  more  rarely  it 
continued  good  to  the  last.  A  small  number  presented,  at 
considerable  intervals,  nausea  and  vomitings  ;  in  only  one  in- 
stance were  epigastric  pains  complained  of.  In  three  others 
this  region  was  rather  sensible  to  pressure  ;  but  this  slight  sen- 
sibility of  the  epigastrium  is  often  present  in  acute  catarrh, 
when  the  cough  is  frequent  and  the  stomach  healthy  ;  it  might 
therefore  in  this  instance  have  been  caused  by  the  cough,  and 
on  that  account  cannot  be  relied  on  as  a  symptom. 

340.  We  have  compared  the  above  symptoms  with  those 
experienced  by  patients  whose  gastric  mucous  membrane  pre- 
sented no  alteration,  either  as  to  color,  consistence,  or  thick- 
ness, and  no  difference  was  observable.  In  both  the  anorexia 
had  commenced  at  very  variable  periods  ;  some  of  the  latter 
had  also  nausea  and  vomiting  at  distant  intervals. 

The  loss  of  appetite  in  cases  where  the  mucous  membrane 


Chap.  5.]  SUMMARY.  281 

of  the  stomach  was  healthy  proves  that  anorexia,  even  when 
protracted,  is  not  sufficient  to  determine  the  presence  of  gas- 
tritis ;  when  not  accompanied  with  pain,  nausea  and  vomitings, 
it  aids  little  in  the  diagnosis,  and  is  another  proof  (259),  that 
a  function  may  be  for  a  long  time  deranged,  without  any  ap- 
preciable alteration  of  structure  in  the  organ  which  discharges 
it.  Besides,  if  the  mamillated  state  of  the  mucous  membrane 
be  the  result,  as  we  believe  it  is,  of  very  chronic  inflammation, 
we  can  perceive  the  difficulty  of  recognizing  its  symptoms  in 
a  disease  in  which  the  functions  of  the  stomach  are  deranged 
even  when  its  mucous  membrane  is  perfectly  healthy.  This 
would  not,  perhaps,  be  the  case  were  there  no  co-existing 
complication  ;  at  least  we  may  presume  so,  from  what  occur- 
red in  the  twenty-second  observation. 

341.  When  the  gastric  mucous  membrane  was  more  or  less 
red  in  its  ivhoh  extent,  without  any  alteration  of  thickness 
or  consistence,  we  have  observed  distinct  symptoms  (as  epi- 
gastric pains  or  nausea)  a  few  days  only  before  death  ;  symp- 
toms which  indicated  recent  inflammation,  and  this  was  verified 
by  the  nature  of  the  appearances  after  death. 

342.  From  what  has  preceded,  we  may  conclude  that  the 
greater  number  of  the  morbid  conditions  of  the  stomach  is 
characterised  by  peculiar  symptoms.  When  it  was  thinned 
and  softened,  loss  of  appetite,  nausea,  bilious  vomitings,  epi- 
gastric pains  were  almost  constantly  present,  and  generally 
some  time  before  death.  When  the  inflammation  was  con- 
fined to  the  anterior  surface  of  the  stomach,  the  symptoms 
were  much  less  urgent,  commonly  less  numerous,  and  of 
shorter  duration  ;  the  loss  of  appetite  was  more  or  less  con- 
siderable ;   there  were  nausea  and  epigastric  pains,  though  not 


282  SYMPTOMS.  —  GASTRIC  J  [Part  II, 

violent,  and  in  one  fourth  of  the  cases,  vomiting.  The  same 
symptoms  were  observed  when  the  ulcerations  were  large,  or 
when  they  were  small  and  numerous.  When  the  inflamma- 
tion was  confined  to  the  mucous  membrane  of  the  great  cul- 
de-sac  there  were  no  vomitings  ;  nausea  and  epigastric  pains 
were  seldom  observed  ;  this  frequent  absence  of  symptoms 
made  us  conclude  that  this  inflammation  came  on  towards  the 
close  of  the  disease,  and  perhaps,  in  some  cases,  like  pneu- 
monia and  pleurisy,  in  the  last  twenty-four  or  forty-eight  hours. 
Finally,  no  symptom  positively  indicated  the  mamillated  state 
of  the  mucous  membrane,  and  when  it  was  universally  red 
without  any  change  of  thickness,  or  consistence,  a  part  of  the 
patients  experienced  nausea  and  epigastric  pains  two  or  three 
days  before  death. 

This  simple  statement  of  facts  points  out,  we  think,  very 
clearly  in  what  light  we  ought  to  regard  vomitings  which  oc- 
cur in  the  progress  of  phthisis,  vomitings  which  have  hitherto 
been  classed  among  the  symptoms  of  the  disease.  When 
they  have  been  preceded  during  a  certain  time  by  more  or 
less  anorexia,  and  accompanied  with  epigastric  pains,  they  are 
generally  indicative  of  a  very  serious  alteration  of  the  mucous 
membrane  of  the  stomach  ;  and  this  union  of  symptoms  is 
what  we  most  generally  observed.  Vomitings  can  be  much 
less  frequently  attributed  to  the  cough  ;  and  in  these  cases- 
there  is  no  epigastric  pain,  the  appetite  is  good,  the  digestion 
easy,  and  they  occur  generally  at  the  commencement  of  the 
disease  ;  but  when  resulting  from  organic  alteration  they  are 
almost  invariably  confined  to  a  more  or  less  advanced  period  of 
the  affection. 

But  here,  as  in  a  thousand  other  circumstances,  there  are 
facts  which  defy  the  sagacity  of  the  observer,  and  seem  excep»- 
tions  to  the   most  general  laws.     One  of  our  patients,  for  in- 


Ghap.  5.]  SUMMARY.  2S3 

stance,  presented  during  the  last  month  of  life,  pains  in  the  epi- 
gastrium, nausea  and  vomitings,  either  during  the  cough  or  in  its 
intervals,  although  the  gastric  mucous  membrane  was  perfectly 
^healthy. 

343.  To  conclude  our  remarks  on  the  state  of  this  mem- 
brane in  cases  of  phthisis,  we  shall  relate  two  facts,  one  of 
which  seems  an  instance  of  chronic  gastritis,  with  an  ulcera- 
tion, as  if  cicatrized  ;  the  other  an  example  of  complete  de- 
struction of  the  muscular  tunic  in  one  spot,  while  the  corres- 
ponding mucous  and  submucous  layers  were  unaiîected. 


TWENTY-FIRST     OBSERVATION. 

A  SHOEMAKER,  ffit.  34,  of  middle  height,  rather  delicate 
constitution,  addicted  to  onanism  from  an  early  age,  entered 
the  hospital  of  La  Charité,  July  12th,  1S24.  He  had  en- 
joyed habitually  good  health  ;  had  never  been  seriously  ill  ; 
was  not  liable  to  colds.  He  dated  his  present  illness  a  year 
and  a  half  ago,  had  ceased  his  occupation  five  months,  and 
attributed  his  indisposition  to  great  grief  at  the  loss  of  his  sav- 
ings. He  was  first  attacked  by  slight  diarrhœa,  accompanied 
with  almost  complete  anorexia.  These  symptoms  continued 
without  variation  during  eleven  months,  with  only  slight  epi- 
gastric pains  occasionally,  but  without  fever,  nausea  or  vomit- 
ings. After  this  period  he  was  seized,  without  evident  cause, 
in  the  middle  of  the  night,  with  a  copious  hemoptysis,  which 
returned  on  the  two  following  days,  and  seemed  at  length  to 
yield  to  strongly  acidulated  drinks.  At  the  same  time  there 
were  cough,  expectoration  and  dyspnœa,  with  vomitings  after 
the  cough  ;  after  that  period  the  diarrhoea  ceased  ;  soon  after 


284  SYMPTOMS.  —  gastric;  [Part  II, 

the  appetite  returned,  and  during  the  last  four  months  there 
were  night  perspirations,  rarely  preceded  by  rigors.  He  had 
never, experienced  pains  in  the  chest.  July  13th.  General 
paleness  of  surface  ;  great  debility  ;  pain  in  the  limbs  ;  varia- 
ble state  of  thirst  ;  tongue,  natural  ;  no  tenderness  in  the  epi- 
gastrium ;  daily  stools,  of  natural  firmness.  Pulse,  small  and 
weak,  slightly  accelerated  ;  heat,  moderate,  with  evening  ex- 
acerbation ;  night  sweats.  Respiration,  loud  and  almost  cav- 
ernous round  the  summit  of  the  left  lung,  natural  and  free  from 
râle  every  where  else  ;  speaks  hurriedly  ;  slight  dyspnœa  ; 
sputa,  greenish,  in  small  irregular  masses,  and  scanty.  Con- 
siderable emaciation. 

(Decoction  of  lichen;  gum  potion;  julep;  one  fourth  of 
house  allowance). 

Up  to  the  8th  of  August  there  was  neither  nausea  nor 
vomiting;  the  appetite  improved  and  the  digestion  was  easy  ; 
the  skin  was  always  rather  hot  in  the  evening  with  occasional 
perspirations  during  the  night  ;  diminution  of  dyspnœa,  but 
great  debility. 

The  patient  having  quitted  the  hospital  at  this  period,  on 
the  following  day  there  were  great  increase  of  cough,  renewal 
of  the  vomiting  and  loss  of  appetite.  This  compelled  him  to 
re-enter,  and  from  the  10th  of  August  to  the  2d  of  November, 
the  following  is  the  result  of  our  observatious  :  —  Cessation  of 
vomitings  and  no  subsequent  recurrence  ;  the  appetite  con- 
tinued depressed  during  some  days,  but  soon  after  was  as  good 
as  in  the  report  of  August  8th;  after  the  invasion  of  diarrhœa 
on  the  2d  of  October  it  diminished,  and  continued  inconsider- 
able to  the  last.  There  w^as  no  epigastric  suffering,  and  the 
looseness,  which  was  at  first  violent,  with  great  prostration 
and  rapid  pulse,  quickly  diminished.  The  tongue  was  almost 
always  a  little  red,  and  rather  livid  ;  the  heat  of  surface  in- 


Chap.  5.]    CHRONIC    GASTRITIS    WITH    ULCERATION.  285 

creased  in  the  evening  and  during  the  night  ;  very  rarely 
there  vi^ere  perspirations  and  rigors. 

Sept.  2-2d.  Percussion  under  the  left  clavicle,  very  dull  ;  this 
gradually  extended,  and  in  the  middle  of  October  there  vi^as 
every  where  loss  of  sound  anteriorly  on  the  same  side.  The 
respiration  under  both  clavicles  was  tracheal,  and  was  soon 
followed  by  gurgling. 

There  was  sudden  increase  of  the  prostration  on  the  1st  of 
November,  and  on  the  2d,  at  five,  p.  m.,  the  patient  expired. 

During  a  few  days  rice  water  was  prescribed,  and  afterwards 
the  infusion  of  violets.  During  the  last  month  he  only  took 
a  little  soup  and  some  rice  creams. 

Opening  of  the  corpse  forty  hours  after  death. 

Exterior.  —  Extreme  emaciation.  Nothing  else  remark- 
able. 

Head.  —  Slight  sub-arachnoidean  infiltration  ;  a  spoonful 
of  fluid  in  each  lateral  ventricle,  rather  less  at  the  base  of  the 
skull  ;  brain,  soft  and  injected. 

Neck.  —  Epiglottis,  natural.  Larynx,  pale,  with  two 
superficial  ulcerations,  one  at  the  union  of  the  vocal  cords  and 
the  other  on  the  left  inferior  one.  Tracheal  mucous  mem- 
brane rather  red,  with  numerous  ulcerations  of  a  line  in  diam- 
eter, without  any  thickening  of  the  membrane  either  around 
them,  or  in  their  intervals.  Some  similar  ulcerations  in  the 
left  bronchia. 

Thorax.  —  Slight  adhesions  at  the  summit  of  both  lungs. 
The  upper  lobe  of  the  left  lung  presented  two  large  excava- 
tions, lined  by  a  greyish,  semi-cartilaginous,  somewhat  opaque 
membrane,  filled  with  a  greenish  matter,  analogous  to  what 
existed  in  the  bronchia  ;  the  remainder  of  the  lobe  was  con- 
verted into  a  greyish,  semi-transparent  substance,  containing 


286  SYMPTOMS.  —  gastric;  [Part  II, 

numerous  half-filled  small  excavations,  many  of  which  were 
only  separated  from  the  pleura  by  an  extremely  thin  layer. 
In  the  summit  of  the  lower  lobe  there  was  a  small  quantity 
of  grey,  semi-transparent  matter,  interspersed  with  tubercles. 
In  the  right  lung  the  lesions  were  of  a  similar  description,  but 
less  extensive.  Heart,  healthy  ;  numerous  semi-cartilaginous 
spots  in  the  interior  of  the  aorta. 

Abdomen.  —  Stomach,  of  moderate  volume,  rather  con- 
tracted at  the  centre.  Its  mucous  membrane  of  a  tawny 
color  in  the  cul-de-sac,  more  or  less  greyish  elsewhere  ;  this 
last  tint  was  interrupted  by  some  whitish-colored  spots,  from 
one  to  two  lines  in  diameter,  where  the  membrane  was  evi- 
dently thinned.  One  of  these,  of  a  very  light  grey,  oval,  seven 
lines  long  and  five  wide,  situated  posteriorly  near  the  small 
curvature,  and  half  way  between  the  cardia  and  pylorus. 
The  mucous  membrane  seemed  insensibly  to  terminate  at  its 
circumference,  after  having  gradually  decreased  in  thickness 
over  an  inch  and  a  half  of  surface.  This  termination  was  the 
more  indistinct  on  account  of  the  color  of  the  mucous  mem- 
brane being  similar  to  that  of  the  spot  we  have  described, 
which  was  itself  formed  by  the  submucous  layer  ;  so  that  after 
having  removed  all  the  mucous  membrane  the  stomach  was 
white  with  the  exception  of  this  spot.  The  latter  was  also 
circumscribed  by  a  thin  flattened  ring,  about  one  line  in 
breadth,  formed  by  the  firm  adhesion  of  the  submucous  layer 
to  the  subjacent  muscular  tunic.  The  consistence  of  the 
mucous  membrane,  where  thinned,  was  rather  diminished. 
The  muscular  coat  presented  no  alteration.  The  lining  mem- 
brane of  the  small  intestine  was  of  normal  consistence  and 
thickness,  and  offered  numerous  narrow,  transverse  ulcerations 
in  the  three  upper  fourths,  and  in  the  lower  portion  pretty 
numerous  yellowish  granulations,  of  a  tuberculous  appearance, 


Chap.   5.j     CHRONIC    GASTRITIS    WITH    ULCERATION.  287 

of  the  size  of  a  pea  or  smaller,  and  ulcerated  at  their  summit. 
There  were  numerous  ulcerations  in  the  large  intestine,  from 
one  to  two  inches  in  surface  ;  smaller  in  the  rectum  than  else- 
where. The  greater  number  was  rough,  from  the  promi- 
nence of  the  denuded  fibres  of  the  muscular  coat,  which  were 
a  half  a  line  thick  ;  around  them  the  mucous  membrane  was 
red  and  thickened  ;  in  other  parts  this  last  was  healthy.  The 
raesocolic  glands,  about  the  size  of  a  pea,  were  tuberculated 
and  firm;  those  of  the  mesentery  were  unaltered.  There 
was  only  one  kidney;  it  was  situated  to  the  right,  nearly 
twice  the  usual  volume,  with  two  fissures,  one  anterior,  the 
other  at  its  internal  edge,  and  two  small  pelves,  which  termi- 
nated after  a  short  distance  in  a  single  ureter. 

344.  The  loss  of  appetite  experienced  by  the  patient  eleven 
months  before  the  accession  of  cough,  when,  as  far  as  we  can 
judge,  no  tuberculous  affection  of  the  lungs  existed,  is  no  doubt 
to  be  ascribed  to  a  chronic  inflammation  of  the  mucous  mem- 
brane of  the  stomach,  of  which  the  diminished  consistence  and 
partial  destruction  were  the  consequence.  In  general,  when  a 
certain  portion  of  this  membrane  is  destroyed,  the  adjacent  parts 
are  natural,  or  at  least  offer  neither  increase  nor  diminution  of 
thickness  ;  the  lining  submucous  layer  presents  no  change  of 
color,  but  is  occasionally  a  little  thickened  or  partially  destroy- 
ed, as  we  have  already  seen  in  the  thirty-eighth  observation  ;  it 
also  does  not  form  any  elevated  boundary  around  the  mucous 
membrane.  Does  not  the  difference  between  these  characters 
and  those  of  the  ulcerations  just  described  prove,  when  con- 
nected with  the  history  of  the  symptoms,  that  there  had  been 
a  very  chronic  gastritis,  with  ulceration  of  the  mucous  mem- 
brane which  had  undergone  a  partial  cicatrization  ?  It  may 
perhaps  be  argued,  that  were  this  the  case,  the  mucous  mem- 


288  sïMPTOMS.  —  GASTRIC  ;  [Part  II, 

brane  would  have  reached  beyond  the  indurated  and  circum- 
scribed boundary  ;  we  can  only  say  that,  in  the  few  examples 
we  possess  of  distinct  cicatrization  in  the  small  intestine,  the 
mucous  membrane  never  extended  beyond  the  circumference 
of  the  ulceration. 


TWENTY-SECOND     OBSERVATION. 

345.  A  WOMAN,  set.  49,  a  gold  wire  drawer,  of  a  weak  con- 
stitution, seldom  liable  to  colds,  entered  the  hospital  of  La 
Charité,  July  13th,  1824.  She  had  been  ill  a  year,  and  had 
ceased  her  business  five  weeks.  At  the  commencement, 
general  uneasiness,  sense  of  debility,  partial  loss  of  appetite, 
and  emaciation.  In  the  fifth  month,  cough,  expectoration 
and  dyspnœa  (which  afterwards  were  continued)  were  con- 
joined with  the  previous  symptoms  ;  during  the  last  month 
complete  loss  of  appetite  and  diarrhoea.  In  the  fourth  month 
pains  and  pricking  sensations  in  the  right  side  of  the  chest, 
which  have  been  more  or  less  urgent  ever  since.  No  haemop- 
tysis, night  perspirations,  or  epigastric  pains,  and  she  was  very 
rarely  sensible  of  rigors. 

July  14th.  Considerable  debility  ;  extreme  emaciation  j 
some  oedema  of  the  lower  part  of  the  legs.  Tongue,  a  little 
red  at  the  point  ;  mouth,  clammy,  and  with  occasional  bitter 
taste  ;  thirst,  variable;  very  little  appetite  ;  marked  resistance 
to  the  hand  in  the  epigastric  region  and  below  the  right  false 
ribs,  for  a  space  of  three  inches  ;  no  pain  in  the  correspond- 
ing parts  ;  epigastric  pulsation  the  last  few  days  ;  one  liquid 
stool  and  slight  tension  in  the  hypogastric  region.  Cough, 
frequent  in  the  morning,  with    some    greenish  and  opaque 


Chap.  5.]    DESTRUCTION    OF    THE    MUSCULAR    COAT.  289 

sputa  ;  on  the  right  side  and  anteriorly  there  was  dulness  on 
percussion;  ahnost  the  same  was  observed  in  the  correspond- 
ing point  posteriorly.  Respiration,  tracheal  under  the  right 
clavicle  with  gurgling  and  pectoriloquy  over  a  considerable 
extent  ;  the  decubitus  on  the  right  side  provoked  cough  and 
increased  the  dyspnoea.     Pulse,  rather  full  and  quick. 

(Rice  water  with  quince  syrup  ;  gum  potion  ;  three  rice 
creams). 

The  anorexia  continued,  the  diarrhoea  increased,  became 
copious,  and  then  entirely  ceased  after  the  beginning  of  Au- 
gust. There  were  neither  nausea,  vomiting,  nor  epigastric 
pains.  The  hypogastrium  was  the  seat  of  a  very  trouble- 
some sensation  of  weight,  principally  felt  after  food,  which 
sometimes  consisted  of  an  egg  and  a  small  quantity  of  bread  j 
there  was  slight  tympanitis.  The  stools  became  very  fre- 
quent and  offensive  the  last  four  days,  and  at  nine,  a.  m.,  of 
the  17th  of  August,  the  patient  expired. 

During  the  thirty-three  days  on  which  we  observed  this 
patient,  the  state  of  tlie  tongue  was  very  variable  ;  its  color, 
though  usually  natural,  was  at  times  more  or  less  red,  without 
any  accompanying  change  in  the  functions  of  the  stomach  and 
intestines.  The  heat  of  the  skin  was  elevated  in  the  evening  ; 
there  were  no  perspirations,  and  the  results  of  the  examination 
of  the  chest  were  nearly  the  same  as  at  the  first.  Diascor- 
diura,  with  a  grain  of  opium,  was  prescribed  when  the  diar- 
rhœa  was  urgent. 

Opening  of  the  corpse  tiventy-three  hours  after  death. 

Exterior.  — Extreme  emaciation. 

Head.  — A  small  spoonful  of  fluid  on  the  upper  surface  of 
M  2 


290  SYMPTOMS.  GASTRIC  J  [P^rt  II, 

the  arachnoid  ;  some  slight  emphysema  between  this  mem- 
brane and  the  pia  mater,  without  infiUration.  A  spoonful  of 
fluid  in  each  lateral  ventricle  ;  the  lower  half  of  the  brain  was 
less  firm  than  the  upper.  The  tuber  annulare  and  the  spinal 
marrow  were  still  more  softened.  Three  spoonsful  of  sUghtly 
frothy  fluid  in  the  lower  portion  of  the  vertebral  canal. 

Neck.  —  Epiglottis,  larynx  and  trachea,  healthy. 

Thorax.  —  Left  lung,  without  adhesions;  its  upper  lobe 
was  much  nodulated  with  many  granulations,  crude,  or 
softened  tubercles,  placed  very  superficially  ;  these  were  nu- 
merous internally  also  ;  very  few  existed  in  the  lower  lobe. 
The  right  lung  was  universally  adherent  to  the  costal  pleura, 
by  means  of  a  semi-cartilaginous  false  membrane.  At  the 
summit  of  the  upper  lobe  there  was  a  vast  anfractuous  exca- 
vation, lined  by  a  very  dense,  greyish  false  membrane,  half  a 
line  thick,  inclosing  a  greenish  substance  streaked  with  blood, 
and  intersected  by  some  short  interrupted  bands.  In  the 
remainder  of  its  extent  the  upper  lobe  was  indurated  and 
transformed  superiorly  into  a  dark,  homogeneous,  greyish, 
hard  and  slightly  elastic  substance,  more  or  less  semi-trans- 
parent inferiorly  ;  it  was  crossed  by  irregular  semi-cartilagi- 
nous bands,  and  contained  either  softened  tubercles  or  small 
excavations.  The  bronchia  were  thickened,  more  dilated  and 
redder  in  the  right  upper  lobe  than  in  the  left.  The  heart 
was  small  but  healthy  ;  there  were  numerous  yellowish  patches 
throughout  the  whole  aorta. 

Abdomen.  —  The  peritoneal  cavity  contained  a  quart  and  a 
half  of  reddish  fluid.  The  liver  descended  four  inches  below 
the  ribs,  extending  as  far  as  the  iliac  crest  ;  its  structure  was  firm 
and. brittle.  The  gall-bladder  contained  a  very  dark-colored 
viscous  fluid.  The  stomach  was  small  and  closely  adherent 
by  part  of  its  posterior  surfiice  to  the  pancreas,  the  tissue  of 


Chap.   5.]     DESTRUCTION    OF    THE    MUSCULAR    COAT.  291 

which  was  much  indurated  ;  the  mucous  membrane  presented 
a  greyish  pink  tinge  ;  it  was  every  where  mamillated  and 
rather  thickened,  with  diminished  consistence  in  the  large 
curvature,  and  covered  with  a  copious  and  viscous  mucus. 
Near  the  small  curvature,  between  the  cardiac  and  pyloric 
orifices,  and  in  the  portion  adhering  to  the  pancreas,  there 
was  a  slight  depression,  about  the  size  of  a  dollar,  round  which 
the  mucous  membrane  was  a  little  corrugated.  In  the  de- 
pressed portion  it  was  very  thin  and  brittle,  but  not  mamil- 
lated ;  the  corresponding  cellular  layer  was  healthy  ;  the  mus- 
cular membrane  was  destroyed  and  replaced  by  a  white,  semi- 
cartilaginous  tissue,  about  a  quarter  of  a  line  thick,  in  which 
the  fleshy  fibres  terminated.  These  were  m.ore  than  half  a 
line  thick  at  the  point  of  junction,  for  a  space  of  four  lines, 
but  were  not  otherwise  modified  ;  the  submucous  layer  was 
indurated  and  thickened  to  the  same  extent.  The  small  in- 
testine contained  a  greyish,  thin,  tenacious  substance,  with  a 
faint  odor;  its  lining  membrane  was  a  little  softened,  present- 
ing throughout,  numerous  small  ulcerations,  many  of  which 
were  in  the  centre  of  the  glandular  patches.  Similar  ulcer- 
ations existed  through  the  whole  of  the  large  intestine  as  far 
as  the  anus  ;  they  were  lined  by  the  slightly  thickened  sub- 
mucous tissue.  In  their  intervals  the  membrane  was  as  soft 
as  mucus,  and  twice  its  usual  thickness  ;  it  was  every  where 
in  contact  with  a  greyish  and  reddish  liquid.  The  mes- 
enteric and  mesocolic  glands,  rather  voluminous,  but  healthy. 
Spleen,  small,  of  a  texture  as  firm  as  that  of  the  liver.  Uri- 
nary apparatus,  natural. 

346.  The  state  of  the  gastric  mucous  membrane,  which  was 
grey  and  mamillated  throughout  its  whole  extent,  thinned  in 
one  point,  while  it  was  somewhat  thickened  elsewhere,  and  the 


292  SYMPTOMS.  —  GASTRIC.  [Part  II, 

decrease  of  appetite  long  anterior  to  the  invasion  of  phthisis, 
render  this  observation  very  analogous  to  the  preceding,  and 
prove. the  existence  of  a  chronic  gastritis  long  before  the  ap- 
pearance of  phthisis,  and  for  some  time  without  complication. 
In  this  respect  the  fact  is  one  of  great  interest,  as  it  shows 
what  as  yet  we  have  only  ventured  to  intimate,  that  the  mam- 
illated  state  of  the  mucous  membrane  of  the  stomach  is  the 
result  of  a  chronic  affection,  characterized  by  very  obscure 
symptoms.  Hitherto  we  have  never  observed  this  condition 
isolated  from  more  or  less  numerous  complications,  and  since 
in  these  cases  the  gastric  symptoms  closely  resembled  those 
we  observe  when  the  stomach  is  healthy  (339,  340),  it  was 
impossible  to  know  to  what  they  might  be  referred.  The  ob- 
servation before  us  proves,  more  evidently,  that  the  symptoms 
are  exceedingly  obscure,  and  doubtless  confined  in  the  ma- 
jority of  instances  to  a  greater  or  less  diminution  of  appetite 
with  difficult  digestion.  We  do  not  say  this  is  always  the 
case,  for  we  have  had  examples  in  which  this  condition  of  the 
membrane  was  combined  with  redness,  and  in  these  cases 
there  were  occasional  nausea  and  epigastric  pains  (90,  326). 

The  partial  transformation  of  the  muscular  coat  into  a  semi- 
cartilaginous  substance  is  equally  worthy  of  our  attention. 
Without  conjecturing  when  this  might  have  taken  place,  or 
the  exact  cause  which  produced  it,  we  shall  only  remark  that 
we  have  lately  met  with  a  very  analogous  fact  ;  but  instead  of 
the  semi-cartilaginous  transformation,  the  muscular  tunic  was 
here  converted  into  a  fibrous  tissue  about  half  a  line  thick. 
The  corresponding  cellular  layer  was  more  or  less  thickened. 


Chap.  5.]  TONGUE,    ITS    COLOR.  293 


ARTICLE    V, 


STATE  OF  THE  TONGUE. 


347.  It  is  proper,  after  having  studied  the  symptoms  which 
correspond  to  the  different  conditions  of  the  gastric  mucous 
membrane,  to  investigate  whether  there  is  not  some  dépend- 
ance between  these  conditions  and  the  state  of  the  tongue. 
The  following  is  the  result  of  our  inquiry  :  —  Out  of  nineteen 
cases  with  softening  and  diminished  thickness  of  the  mucous 
membrane  of  the  stomach,  in  nine  the  tongue,  which  was  al- 
ways moist,  never  presented  at  any  period  of  the  affection 
distinct  redness  ;  and  out  of  ten  others  it  was  red  at  the  point 
and  edges  in  four,  during  fifteen  or  twenty  days  ;  while  in  the 
remaining  six  this  v^'as  the  case  for  a  very  limited  period,  only 
two  or  three  days. 

348.  In  eight  examples  where  the  inflammation  was  con- 
fined to  the  anterior  part  of  the  gastric  mucous  membrane,  in 
half  the  tongue  was  red,  in  the  rest  it  was  pale.  In  one  the 
redness  was  very  transitory. 

349.  When  the  inflammation  occupied  the  totality,  or  a 
portion  of  the  great  cul-de-sac  of  the  stomach  (in  w^iich  case, 
as  we  have  remarked,  it  probably  dated  but  a  few  days  before 
death),  the  tongue  was  natural  in  ten  instances;  while  in 
seven  others  it  was  more  or  less  red  on  the  edges,  either  very 
shortly  before  the  fatal  termination,  or  during  a  few  days  only, 
at  some  earlier  period. 

350.  In  patients  where  the  mucous  membrane  was  evidently 
mamillated;  the  tongue  was  more  or  less  red  during  a  varia- 
ble space  of  time  in  eight  out  of  nineteen  ;  in  the  remain- 


294  SYMPTOMS.  —  tongue;  [Part  U, 

der  it  was  natural.  In  six  out  of  fourteen  other  examples, 
where  the  gastric  mucous  membrane  presented  a  variety  of 
morbid  alterations,  the  tongue  was  redder  than  natural  for  one 
or  more  weeks. 

351.  Lastly,  where  the  mucous  membrane  was  healthy, 
both  as  to  color,  consistence  and  thickness,  the  tongue  was 
more  or  less  red  in  ten  out  of  nineteen  ;  and  in  one  of  these 
the  redness  persisted  during  the  whole  course  of  the  disease, 
and  was  more  intense  than  in  any  of  the  preceding  instances  ; 
the  tongue  also  at  one  period  became  dry,  as  we  occasionally 
see  it  in  continued  fever.  The  observation  is  sufficiently  in- 
teresting to  be  detailed. 


TWENTY-THIRD     OBSERVATION. 

A  WHEELWRIGHT,  agt.  25,  of  a  tolerably  strong  constitu- 
tion, had  been  ill  three  weeks  when  he  was  admitted  into  the 
hospital  of  La  Charité  ;  he  said  that  seven  months  previously 
he  had  been  attacked  with  continued  fever,  which  lasted  five 
weeks,  but  had  not  been  accompanied  with  diarrhoea;  his 
convalescence  was  rapid  and  complete  ;  his  digestion  had 
been  easy  and  regular,  and  his  appetite  excellent  up  to  the 
period  of  his  present  illness.  During  the  first  eight  days  of 
this  last  affection  he  had  complained  of  uneasiness,  loss  of  ap- 
petite, thirst,  slight  cough  and  inaptitude  for  exertion  ;  this 
was  followed  by  increased  heat  without  rigors,  night  perspira- 
tions, intense  thirst,  complete  anorexia,  increased  cough,  pains 
under  the  sternum,  throbbing  in  the  ears  on  assuming  the  ver- 
tical position,  and  confinement  to  his  bed.  Leeches  were 
applied  to  the  epigastrium   (where  no   pain  had  been  ex- 


Chap.  5.]  ITS  REDNESS.  295 

perienced),  without  the  shghtest  rehef  to  any  of  the  symp- 
toms. 

On  the  3d  of  August,  1824,  the  day  after  his  admission,  his 
state  was  the  following  : — Face,  rather  animated  ;  he  complains 
much  of  weakness  ;  tongue,  dry,  shining,  of  a  bright  red  on 
the  edges,  yellowish,  moist  and  villous  in  the  middle  ;  urgent 
thirst,  anorexia,  bitter  taste  in  the  mouth,  no  pain  in  the  epi- 
gastrium ;  the  whole  of  abdomen  is  insensible  to  strong  pres- 
sure ;  constipation.  Pulse,  seventy-five,  active,  full  ;  heat, 
elevated  ;  breathing,  not  accelerated  ;  no  râle  in  any  part  of 
the  chest  ;  the  cough  causes  pain  under  the  sternum  ;  expec- 
toration, scanty,  spumous  ;  position  in  bed,  natural  ;  slight 
general  uneasiness. 

(Lemonade  ;  an  emollient  enema,  and  diet). 

On  the  following  days  the  tongue  was  moist,  clean,  and 
intensely  red  ;  there  were  one  or  two  liquid  stools  in  the 
twenty-four  hours  ;  the  anorexia  continued,  and  the  lemonade 
appearing  to  produce  some  uneasiness  in  the  epigastrium,  it  was 
changed  for  a  solution  of  simple  oxymel  ;  pulse,  slower  than 
at  first.  11th.  No  change  in  the  state  of  the  tongue  or  di- 
gestive tube;  the  solution  of  oxymel  was  not  supported  better 
than  the  lemonade  ;  the  patient  vomited  a  little  bile.  His 
only  complaint  was  of  the  chest,  at  the  posterior  part  of  which 
on  the  right  side,  there  was  a  slight  sonorous  râle. 

(Solution  of  gum  syrup). 

Until  the  8th  of  September,  when  death  took  place,  the 
thirst  was  more  or  less  urgent,  anorexia  constant,  no  pain  in 
the  epigastrium  ;  some  bile  was  vomited  on  the  22d,  29th, 
and  30th  of  August.  The  tongue  presented  some  variations. 
On  the  16th  it  was  of  a  deep  red  color  and  rather  dry  ;  on 
the  28th  it  offered  the  same  aspect  with  the  addition  of  some 
small  white  apthous  patches  round  the   edges  ;  it  was  unusu- 


296  SYMPTOMS.  —  TONGUE  ;  [Part  II, 

ally  red  on  the  1st  of  September,  perfectly  clean  and  smart- 
ing. This  redness  daily  increased,  and  on  the  5th  was  asso- 
ciated with  dryness  and  augmented  thickness,  which  continued 
to  the  last.  The  stools  became  rare  ;  during  the  last  eight 
days  there  were  some  diarrhoea  and  tympanitis.  August  16th. 
Increased  oppression.  21st.  The  pain  in  the  chest,  cough, 
and  dyspnoea  continued  stationary  ;  the  respiratory  murm.ur 
was  weaker  anteriorly  on  the  left  side  than  on  the  right;  ex- 
pectoration, scanty,  rather  greenish  and  opaque  ;  this  contin- 
ued to  the  last.  The  pulse,  which  was  almost  natural  on  the 
23d  of  August,  was  eighty-five  on  the  28th  ;  there  was  pro- 
portionate increase  of  temperature,  which  afterwards  continued. 
From  the  28th  of  August,  rapid  increase  of  weakness  and 
emaciation,  and  soon  the  patient  was  unable  to  leave  his  bed. 
He  expired  with  very  little  pain  and  no  delirium,  and  almost 
without  any  rattling  respiration,  at  four,  p.  m. 

The  solution  of  gum  syrup  was  continued  with  emollient 
enemas.  On  the  16th  of  August  and  3d  of  September, 
leeches  were  applied  to  the  anus  without  any  advantage. 

Opening  of  the  cor'pse  sixteen  hours  after  death. 

Exterior.  —  Extreme  emaciation. 

Head.  —  Slight  sub-arachnoidean  infiltration;  medullary 
substance  of  the  brain,  rather  vascular;  a  spoonful  of  serous 
fluid  in  each  lateral  ventricle,  and  also  at  the  base  of  the 
skull. 

Neck.  —  Epiglottis,  larynx  and  trachea,  natural. 

Chest.  —  Cellular  adhesions  over  the  greater  part  of  the 
lungs.  The  upper  lobes  contained  numerous  softened  tuber- 
cles, especially  those  of  the  right,  and  anteriorly  rather  than 
posteriorly  ;  in  other  parts  they  were  not  softened.     The  sub- 


Chap.  5.]  USE  IN  PROGNOSIS.  297 

stance  of  the  lung  surrounding  them  seemed  every  where 
heahhy,  and  there  were  no  grey,  semi-transparent  granula- 
tions. Bronchia,  thin,  and  of  a  pale  pink  color  ;  heart  and 
aorta,  natural. 

Abdomen.  —  Stomach,  small,  with  numerous  valvular  folds 
internally.  Lining  membrane,  velvet-like,  pale,  not  in  the 
least  injected,  and  every  where  of  normal  thickness  and  con- 
sistence. The  same  paleness  and  healthy  state  of  the  mucous 
membrane  existed  throughout  the  whole  of  the  small  intes- 
tine, with  the  exception  of  a  small,  very  pale  ulceration,  one 
line  in  diameter,  and  about  twelve  inches  from  the  caecum. 
The  lining  membrane  of  the  large  intestine  w'as  white,  of  nat- 
ural thickness  and  consistence,  except  in  the  last  tv/o  feet, 
where  it  was  of  a  livid  red,  softened,  and  had  numerous  small 
ulcerations,  at  the  centre  of  which  there  were  small  coagula 
of  very  dark  colored  blood.  The  mesentery  consisted  of  an 
irregular  flattened  mass,  of  about  an  inch  thick  and  at  least 
thirty  inches  in  superficies,  formed  by  the  union  of  completely 
tuberculated  mesenteric  glands,  not  softened,  and  about  as 
large  as  a  chestnut.  Many  of  the  lumbar  glands  had  partially 
undergone  the  same  transformation.  The  pancreas  was  harder 
and  whiter  than  natural  ;  the  other  viscera  of  the  abdomen 
were  healthy. 

352.  The  absence  of  epigastric  pain  in  this  case  in  which 
the  progress  of  the  symptoms  had  been  tolerably  rapid,  and 
the  intellectual  faculties  had  remained  unaflected,  and  in  which 
only  a  slight  vomiting  of  bile  occurred,  made  us  relinquish  the 
idea  of  gastritis,  and  having  merely  some  suspicions  in  re- 
gard to  the  state  of  the  lungs,  we  were  unable  to  form  any 
rigorous  conclusion  as  to  the  nature  of  the  disease  ;  but  the 
gradual  emaciation,  the  redness  and  dryness  of  the  tongue, 
N  2 


298  SYMPTOMS. — tongue;       [Part  II, 

the  continuation  and  increase  of  the  same  symptoms  made  us 
believe  that  the  disease  was,  and  would  shortly  prove  to  be, 
fatal  in  its  nature.  As  in  many  other  instances,  the  condition 
of  the  tongue  was  useful  for  our  prognosis,  and  we  think  that 
its  value  as  a  symptom  is  almost  wholly  confined  to  this  indi- 
cation. At  least,  after  the  facts  we  have  related,  it  must  ap- 
pear evident  that  there  is  no  real  relation  between  the  state  of 
the  tongue  and  that  of  the  stomach  ;  for  if  it  is  sometimes  red 
in  gastritis,  it  is  still  more  frequently  pale  ;  and,  on  the  other 
hand,,  it  is  sometimes  dry,  hard,  and  intensely  red,  when  the 
gastric  mucous  membrane  is  healthy. 

These  facts,  indeed,  ought  not  to  excite  surprise,  as  they  sim- 
ply prove  that  the  tongue  is  no  exception  to  the  general  laws 
of  the  system,  which  would  be  the  case,  did  it  either  constantly 
or  solely  indicate  the  condition  of  the  gastric  mucous  mem- 
brane. In  fact,  whenever  there  is  febrile  movement,  the 
whole  system  more  or  less  participates  ;  the  appetite  ceases  ; 
the  skin  becomes  hot,  moist,  and  frequently  colored  ;  the 
secretions  are  modified  ;  the  urine  is  red,  scalding,  &ic.  Why 
should  the  tongue  remain  unaffected  by  these  changes  ?  Why 
should  it  not  become  more  or  less  red,  dry,  moist,  clean,  oe 
coated  ?* 

*  Perhaps  there  never  was  an  opinion  in  medicine  more  generally  adopt- 
ed than  that  the  state  of  the  tongue  was  indicative  of  that  of  the  stomach  5 
and  yet  when  brought  to  the  test  of  accurate  observation  its  fallacy  is  at 
once  detected,  and  the  inaccuracy  of  experience  demonstrated.  The  results 
of  our  author  are  not  peculiar  to  himself,  though  perhaps  the  evidence  he 
adduces  is  as  yet  the  most  incontestable.  Dr.  Stokes,  in  his  second  lecture 
during  the  session  of  1832 — 3,  says,  "  the  tongue  is  only  useful  as  an  index  of 
the  general  state  of  the  system,  and  not  of  the  stomach."  Dr.  Piorry,  in  an 
interesting  memoir  on  this  subject,  (Vide  Collection  de  Mémoires  sur  la 
Physiologie,  la  Pathologie  et  le  Diagnostic,  par  M-  Piorry.  Paris,  1831), 
concludes, —  First,  That  the  redness  of  the  tongue  depends  on  the  volume 


Chap.  5.]       ALBUMINOUS    EXUDATION    UPON    IT.  299 

From  the  first  examination,  the  anorexia  was  complete  ; 
and  this  becomes  more  remarkable,  from  the  fact  that  not 
only  was  the  gastric  lining  membrane  healthy,  but  there  was 
scarcely  any  febrile  excitement  present  ;  this  proves  that  loss 
of  appetite  may  exist  without  fever,  or  any  sensible  alteration 
of  the  mucous  membrane  of  the  stomach. 

353.  With  the  exception  of  a  very  small  ulceration,  the 
mucous  membrane  of  the  small  intestine  was  healthy,  while 
the  whole  of  the  mesentery  was  transformed  into  tuberculous 
matter.  Are  we  not  compelled  to  admit  that  this  transforma- 
tion was  quite  independent  of  inflammation  of  the  intestinal 
mucous  membrane,  as  we  have  already  shown  (151)  ? 

354.  In  some  instances  the  tongue  was  the  seat  of  an  albu- 
minous exudation,  which  deserves  more  attention  than  mere 
redness.  This  exudation  was  developed  towards  the  close  of 
the  disease,  four,  eight,  ten,  and  even  sixty  days  before  death  ; 
it  sometimes  presented  the  form  of  patches  from  two  to  three 

and  rapidity  of  the  circulation.  Secondly,  That  in  many  instances  it  is  no 
indication  either  of  gastritis  or  gastro-enteritis.  Thirdly,  That  redness  of  the 
tongue  frequently  accompanies  thoracic  disease.  Fourthly,  That  the  limited 
appearance  of  the  redness  is  owing  to  the  unequal  distribution  of  the  deposit 
on  its  surface;  remove  this,  and  it  becomes  general.  Fifthly,  That  the 
evaporation  of  the  saliva  and  the  secreted  fluids  on  the  surface  of  the  tongue 
is  the  principal  cause  of  its  dryness.  Sixthly,  That  this  dryness  is  rather 
depending  on  the  state  of  the  thorax  than  of  the  digestive  tube.  Seventhly, 
That  the  deposits  on  the  tongue  and  teeth  in  cases  of  fever,  are  the  result  of 
the  desiccation  of  the  saliva,  which  is  itself  modified  by  the  state  of  the  sys- 
tem generally. 

We  refer  the  reader  to  M.  Louis's  work  on  the  Jlffection  Typhoïde,  (vol. 
ii.  pag«  64,  Paris  ;  Translation,  page  55),  for  additional  evidence  on  this 
subject.  The  author's  conclusions  exactly  coincide  with  those  he  has  ad- 
vanced in  the  present  volume.  —  Cowan. 


300  SYMPTOMS.  —  TONGUE  ;       [Part  II, 

lines  in  surface,  which  occasionally  by  their  union  completely 
covered  the  tongue  ;  at  others,  it  assumed  the  form  of  small 
■  points  like  starch,  more  or  less  thickly  scattered,  and  in  their 
intervals  the  substance  of  the  lung  was  denuded.  The  exu- 
dation was  easily  removed,  was  about  a  quarter  of  a  line  thick, 
and  generally  re-appeared  several  times  before  death.  In  the 
majority  of  instances  it  was  simultaneously  present  on  the 
tongue,  lips,  cheeks,  gums,  and  occasionally  on  the  palate. 
Almost  invariably  there  were  pricking  sensations  in  the 
tongue,  heat  and  redness  ;  the  mucous  membrane  was,  how- 
ever, in  some  cases,  very  pale  immediately  beneath  the  exu- 
dation. 

355.  The  redness,  heat,  prickings  with  the  albuminous 
nature  of  the  secretion,*  distinctly  show  an  inflammation  of 
the  mucous  membrane  of  the  tongue.  We  have,  however, 
just  remarked,  that  it  was  occasionally  pale  beneath  the  patches 
and  in  their  intervals,  and  this  is  difficult  to  be  reconciled 
with  inflammation  in  an  organ  so  vascular  as  the  tongue.  Is 
it  a  fact  that  the  albuminous  false  membranes  are  not  always 
dependant  on  inflammatory  action,  and  that  they  may  be  re- 
garded under  certain  circumstances,  as  resulting  from  an  alter- 
ation in  secretion  not  produced  by  inflammation  ?  This  ques- 
tion it  is  very  difficult  satisfactorily  to  answer,  but  after  the  fact 
we  have  stated,  the  inquiry  is  natural.  The  investigation  of 
causes  seldom  leads  us  to  any  useful  result,  and  as  the  ana- 
tomical characters  of  inflammation  are  frequently  obscure,  it 
is,  we  think,  right  to  note  scrupulously  every  thing  that  may 
relate  to  it. 

356.  It  is,  however,  quite  impossible  to  doubt,  that  the  ex- 

*  See  the  Inaugural  Dissertation  ot  M.  Blache.  Pans,  1824.  — 
Lox7is. 


Chap.  5.]    ALBUMINOUS    EXUDATION    UPON    IT.  301 

udation  in  question  is,  in  the  immense  majority  of  cases,  the 
product  of  inflammation,  and  it  thus  forms  an  additional  fact 
to  what  we  have  said  on  the  frequency  of  inflammation  to- 
wards the  close  of  chronic  diseases.* 

357.  The  state  of  the  tongue  we  have  been'describing  is  not 
connected  with  the  condition  of  the  gastric  mucous  membrane 
any  more  than  simple  redness  is.  We  have  observed  it  in  one 
eighth  of  our  cases  ;  three  times  when  there  were  softening  and 
diminished  thickness  of  the  lining  membrane  of  the  stomach  ;  ' 
four  times  when  the  inflammation  was  limited  to  its  anterior 
surface  ;  three  times  when  it  was  perfectly  healthy  ;  and 
twice  among  the  remainder. f 

*  See  the  Summary  of  the  first  part  of  this  work.  —  I.oiris, 

t  M.  Louis  has  found  this  exudation  equally  frequent  towards  the  close 
of  acute  as  well  as  of  chronic  diseases.  It  has  generally  been  classed 
among  the  fatal  symptoms,  but  M.  Louis  has  seen  it  almost  as  often  in  cases 
which  recovered,  as  under  the  opposite  circumstances.  Its  indications 
seem  rather  those  of  general  weakness,  than  of  any  particular  termination. 
—  Cowan. 


302  SYMPTOMS. GENITAL    FUNCTIONS  ;  [Part  II, 


CHAPTER   VI. 

FUNCTIONS   OF  THE    GENITAL   ORGANS. 


ARTICLE    I. 


GEINERATIVE  FUNCTIONS  IN  MEN. 


358.  We  have  frequently  interrogated  phthisical  patients 
in  regard  to  their  desire  for  sexual  intercourse,  and  in  every 
instance  this  desire  has  appeared  to  have  declined  with  the 
increase  of  general  weakness  and  other  symptoms,  almost  ex- 
actly as  is  the  case  with  individuals  laboring  under  any  other 
affection.  It  is,  however,  possible  that  at  the  very  commence- 
ment of  the  tuberculous  affection,  when  there  is  little  diminu- 
tion of  strength,  though  sufficient  to  prevent  the  patients  con- 
tinuing their  usual  occupations,  that  there  should  be  a  more 
evident  inclination  to  sexual  pleasures  than  when  in  perfect 
health  ;  but  this  is  easily  accounted  for  by  the  effect  of  idle- 
ness upon  the  mind,  which  is  then  much  more  under  the 
influence  of  every  impression.  It  would  indeed  be  very  sin- 
gular, when  all  other  functions  are  deteriorated,  that  the  gen- 
erative should  assume  unwonted  activity  ;  this  is  an  additional 
reason  for  us  not  to  admit  so  commonly  received  an  opinion, 
without  undeniable  proof.* 

*  M.  Louis  has  since  continued  his  investigations  on  the  state  of  the  genital 
organs  in  phthisis,  and  has  in  no  instance  discovered  any  evidence  of  their 
increased  activity.     Vide  Examen,  page  45.  —  Cowan. 


Chap.  6.]       SEXUAL    DESIRES  ;    MENSTRUATION.  303 


ARTICLE     II. 

GENERATIVE  FUNCTIONS  IN  WOMEN. 

359.  The  catamenia  were  almost  invariably  suppressed 
sooner  or  later  in  phthisis.  Once  only  they  continued  until 
death,  but  were  irregular,  scanty,  and  during  the  last  three 
months  recurred  every  ten  days.  This  patient  was  ill  nine 
months  and  a  half,  and  during  the  whole  time  did  not  expec- 
torate ;  after  death  we  found  numerous  excavations  in  the 
lungs  ;  the  uterus  was  small  and  healthy.  In  other  instances 
the  menses,  previous  to  their  total  suppression,  were  more  or 
less  irregular,  either  in  quantity,  or  in  their  periods  of  recur- 
rence ;  and,  with  the  exception  of  diminished  volume,  the 
uterus  was  always  perfectly  healthy.  This  fact  is  again  in 
favor  of  what  we  have  more  than  once  insisted  on  (259,  340), 
that  functional  derangement  does  not  necessarily  suppose  any 
appreciable  organic  alteration.* 

*  As  the  uterine  functions  are  usually  depeudant  more  on  the  general 
state  of  the  system  than  on  that  of  the  uterus  itself,  their  irregularity  in  a 
disease  like  phthisis  must  be  regarded  as  an  indication  of  some  general  con- 
dition of  the  constitution,  and  not  of  any  local  disease  of  the  uterus.  Men- 
struation is  not  a  necessary,  but  an  accidental  function  3  and  when  inter- 
rupted by  disease,  the  organ  which  discharges  it  may  remain  indefinitely 
free  from  organic  lesions,  as  is  actually  the  case  both  before  and  after  the 
menstrual  period.  The  same  mode  of  reasoning  may,  we  think,  be  applied 
to- the  skin,  which,  as  the  author  has  remarked,  may  be  the  seat  of  profuse 
perspirations  for  an  indefinite  period,  without  presenting  any  appreciable 
change  of  structure.  The  secretions  on  the  surface  of  the  skin  are  doubtless 
intimately  dependant  on  the  state  of  the  circulation,  respiration,  temperature, 
&c.,  and  we  think  that  in  many  cases  they  are  to  be  regarded  as  purely  phys- 
ical efl'ects  of  simple  exudation,  either  from  an  engorged  state  of  the  capilla- 


304         SYMPTOMS. GENITAL  FUNCTIONS  ;    [Part  11, 

360.  When  the  duration  of  phthisis  was  less  than  one  year, 
the  average  period  of  the  catamenial  suppression  was  about 
the  middle  of  its  progress.  When  the  affection  was  prolonged 
from  one  to  three  years,  the  suppression  occurred  during  the 
last  third.  But,  to  have  a  just  idea  of  the  value  of  this  symp- 
tom, it  is  necessary  to  state  the  limits  of  its  variations.  Thus, 
in  a  young  woman  in  whom  the  disease  lasted  three  years, 
the  catamenia  ceased  at  the  end  of  the  thirteenth  month  > 
while  another  individual  of  the  same  age,  and  in  whom  the 
duration  of  the  disease  was  similar,  continued  to  menstruate 
to  within  two  months  of  the  fatal  termination. 

When  the  progress  of  phthisis  was  chronic,  we  could  not 
detect  any  cause  on  which  the  catamenial  suppression  de- 
pended ;  but  when  the  duration  of  phthisis  was  less  than 
twelve  months,  in  the  majority  of  instances  the  suppression 
coincided  with  the  invasion  of  fever  ;  that  is,  corresponded 
to  the  period  when  the  influence  of  the  principal  affection 
upon  the  functions  of  the  various  organs  became  more  evident 
and  real. 

ries,  diminished  tone  of  the  solids,  or  increased  fluidity  in  the  blood.  Neither 
of  these  examples  is,  we  think,  of  much  weight  in  favor  of  the  opinion  they 
are  intended  to  support,  and  ought  not  to  invalidate  the  generally  received 
opinion,  that  long  continued  functional  derangement  implies  organic  disease. 
Let  it  be  recollected  that  pi-olonf!,ed  functional  disorder  is  never  confined  to 
a  simple  increase  or  decrease  of  what  is  natural,  but  is  invariably  attended 
by  a  change  in  quality  as  well  as  quantity.  The  latter  is  necessarily  de- 
pendant on  adventitious  circumstances,  and  is  often  no  criterion  of  the  state 
of  the  organ  itself;  the  former  may  occasionally  be  so,  but  is  much  more 
frequently  to  be  traced  to  organic  alteration.  The  relation  between  the 
secretion  of  an  organ  and  its  organic  structur-e,  would  be  an  interesting  and 
difficult  subject  of  inquiry.  There  can  be  no  doubt  that  important  changes 
in  the  former  may  take  place  when  no  organic  lesions  can  be  detected. — 
Cowan. 


Chap.  C]  PREGNANCY.  305 

361.  The  menstruation  having  in  some  instances  persisted, 
with  little  variation,  till  within  a  month  before  death,  we  can 
easily  understand  how  pregnancy  can  take  place,  and  go 
through  its  usual  periods  in  the  course  of  phthisis  ;  of  this  we 
have  observed  two  examples. 

The  most  remarkable  instance  is  that  of  a  woman  who  died 
when  in  the  last  stage  of  emaciation,  after  having,  twenty  days 
previously,  given  birth  to  a  robust  child.  Her  lungs  pre- 
sented numerous  excavations. 

362.  We  have  not  been  able  to  decide  whether  pregnancy 
is  capable  of  retarding  the  progress  of  phthisis;  it  is  indeed 
evident  that  numerous  facts  are  required,  and  several  years  of 
observations  in  a  lying-in  hospital,  before  we  can  have  any 
positive  information  on  the  subject.  We  may,  however,  ob- 
serve that  perhaps  there  have  been  some  error  and  confusion 
among  those  who  have  hitherto  admitted  such  an  influence. 
It  is  indeed  possible,  that  many  of  the  sym.ptoms  of  phthisis, 
may  be  less  prominent  during  pregnancy,  while  the  progress 
of  the  disease  is  really  unaffected.  On  the  other  hand,  it  is 
not  impossible  that  after  labor  the  progress  of  phthisis  may  be 
more  rapid  than  at  any  previous  period,  and  this  difference 
before  and  after  confinement,  may,  to  a  certain  extent,  have 
given  rise  to  the  impression.  Is  it  probable,  however,  that 
pregnancy,  itself  a  cause  of  dyspnœa,  should  procrastinate  the 
duration  of  phthisis,  in  which  dyspnoea  is  always  a  more  or 
less  troublesome  symptom  whenever  the  patient  uses  any 
exertion  ? 

o  2 


306  SYMPTOMS.  —  cerebral;  [Part  llj 


CHAPTER    VII 

CEREBRAL    SYMPTOMS. 

363.  In  nearly  every  case  the  intellectual  faculties  were 
undisturbed  until  death  took  place.  In  the  instances  where 
we  have  found  partial  and  pulpy  softening  of  the  brain,  with 
traces  of  inflammation  of  the  lining  membrane  of  the  lateral 
ventricles  or  the  subjacent  tissue,  the  cerebral  symptoms  short- 
ly before  death  were  very  remarkable.  They  were  absent  in 
three  out  of  six  cases,  in  which  there  was  pulpy  softening  ;  we 
have  observed  them  in  one  case  of  arachnitis,  which  we  shall 
now  detail. 


TWENTY-FOURTH    OBSERVATION. 

A  PORTER,  set.  44,  was  admitted  into  La  Charité,  May 
6th,  1824.  He  had  been  a  prisoner  in  England  for  fifteen 
years,  four  of  which  were  spent  in  the  hulks  ;  he  had  coughed 
and  expectorated  the  last  twenty  years  ;  he  was  attacked  with 
haemoptysis  for  the  first  time  in  January  of  the  present  year, 
but  he  had  been  liable  to  oppression  in  his  breathing  for  six 
years,  with  universal  swelling  of  the  whole  body  during  winter, 
which  lasted  about  six  weeks.  The  appetite  had  not  failed  till 
v/ithin  the  last  month,  when  he  began  to  make  use  of  Leroy's 
remedy,  (medicine  de  Leroy ),  of  which  he  took  two  spoons- 
ful a  day.     Having  used  this  fifteen  days  it  produced  a  violent 


Chap.  7.]  ARACHNITIS.  307 

diarrhœa,  which  he  was  unable  to  restrain,  and  for  its  relief  he 
entered  the  hospital. 

Face,  with  a  slight  yellow  tinge  ;  no  headache  ;  cough,  rare  ; 
very  little  oppression;  expectoration,  rather  copious,  greenish, 
not  striated,  slightly  frothy  ;  no  pain  in  the  chest,  nor  had  he 
ever  experienced  any  ;  percussion,  every  where  clear,  except 
under  the  right  clavicle  and  for  some  distance  from  above 
downwards  ;  tracheal  respiration  in  the  same  region  and  pos- 
teriorly between  the  shoulders  ;  pectoriloquy  at  the  right  only  ; 
a  very  coarse  râle,  diminishing  from  the  summit  to  the  base,  was 
was  heard  in  both  lungs  ;  considerable  hoarseness,  with  altera- 
tion of  the  voice  the  last  two  months  ;  no  pain  in  the  larynx  ; 
pulse,  sixty-four  ;  heat,  natural  ;  tongue,  moist,  rather  red 
on  the  edges  ;  mouth,  clammy  ;  no  appetite  ;  pain  in  the  epi- 
gastrium immediately  below  the  xyphoid  cartilage,  both 
from  pressure  and  cough  ;  the  remainder  of  the  abdomen, 
yielding,  and  not  painful  ;  two  liquid  stools  the  previous 
evening. 

On  the  next  day  considerable  diarrhoea  ;  from  eight  to  ten 
stools  ;  the  patient  spent  most  of  his  time  near  the  stove.  On 
the  22d,  almost  constant  drowsiness  ;  intelligence  did  not 
seem  much  confused,  but  patient  said  he  had  lost  his  senses  ; 
no  complaint  of  pain. 

In  the  night  of  the  22d,  some  involuntary  stools  ;  the  pa- 
tient did  not  reply  to  questions,  but  tried  to  get  up,  saying  he 
was  going  home,  and  in  the  attempt  he  fell  upon  the  floor. 
At  seven  in  the  morning  the  expression  was  stupid,  eyes  fixed, 
pupils  contracted  ;  almost  constant  spasmodic  movements  of  the 
masseter  muscles,  and  of  those  of  the  right  arm  ;  stiffness  of  the 
left  arm  and  leg,  with  expression  of  pain  whenever  the  slight- 
est attempt  was  made  to  move  them  ;  the  patient  was  not  quite 
unconscious,  since  he  attempted  to  protrude  the  tongue  when 


308  SYMPTOMS.  —  CEREBRAL  ;  [Part  II, 

asked  to  do  so  ;  pulse,  one  hundred  and  fourteen  ;  no  change 
in  the  respiration. 

(Sinapisms). 

At  eight,  A.  M.,  he  made  an  effort  to  speak,  and  uttered  a 
few  unintelHgible  words  ;  the  arms  and  neck  were  stiff,  resist- 
ing any  attempt  to  move  them.  The  same  sym])toms  con- 
tinued during  the  day  ;  the  breathing  became  ratthng  in  the 
night,  and  on  the  next  day  (24th),  at  eleven,  a.  m.,  he  expired. 

Opening  of  the  corpse  twenty-two  hours  after  death. 

Exterior.  —  Nothing  remarkable. 

Head.  —  Lacerations  of  the  dura  mater,  giving  passage  to 
some  granulations  springing  from  the  arachnoid,  covering  the 
brain,  which  was  opaque  and  thickened  in  the  corresponding 
points.  Two  thin  bony  layers,  nine  lines  large,  were  embedded 
in  the  dura  mater  lying  over  the  left  hemisphere,  near  the  falx. 
Great  distention  of  the  cerebral  veins,  with  sub-arachnoidean 
infiltration.  Brain  itself,  pale,  not  injected,  of  normal  consist- 
ence. The  right  lateral  ventricle  contained  about  two  spoonsful 
and  a  half  of  turbid  fluid,  the  left  rather  less  ;  the  plexus  cho- 
roïdes were  rather  opaque,  and  contained  vesicles  ;  there  were 
three  spoonsful  of  clear  serosity  in  the  lower  occipital  fossae. 

Neck.  —  Larynx  and  epiglottis,  natural  ;  lining  membrane 
of  the  trachea,  rather  red  above  the  bifurcation,  elsewhere  of 
normal  color,  thickness  and  consistence. 

Thorax. — Some  cellular  adhesions  at  the  summit  of  the 
left  lung;  two  linear  osseous  concretions  in  the  upper  lobe; 
slight  engorgement  at  the  centre  of  both  lobes.  Dense  ad- 
hesions over  the  upper  part  of  the  right  lung,  by  means  of  a 
false,  semi-cartilaginous  membrane,  more  or  less  thick.  The 
summit  was  occupied  by  a  rather  large  excavation  ;  lower 
down  there  was  a  very  small  anfractuous  cavity,  where  numer- 


Chap.  7.]  ARACHNITIS.  309 

ous  semi-cartilaginous  lines  terminated,  of  a  bluish  color,  en- 
closing a  greyish-blackish  matter,  formed  by  the  combination 
of  the  melanotic  and  grey,  semi-transparent  substance  ;  this 
cavity  was  red,  like  the  bronchia  that  opened  into  it.  The 
remainder  of  the  upper  lobe  was  indurated  and  transformed 
into  a  grey  substance,  interspersed  with  minute  tuberculous 
excavations.  Some  granulations  of  the  same  nature  existed  in 
the  lower  lobe,  which  was  partially  engorged,  and  presented  at 
its  superior  portion  a  pretty  large  excavation,  lined  by  a  false 
membrane,  and  containing  a  thin,  red  fluid.  The  bronchia 
communicating  with  the  cavities  were  more  or  less  red  and 
thickened  ;  the  others  were  thin,  and  of  a  light  pink  color. 
The  heart  was  rounded  at  the  apex,  rather  larger  than  usual, 
on  account  of  the  increased  size  of  the  left  ventricle,  the  pa- 
rietes  of  which  were  six  lines  thick  ;  aorta,  healthy. 

Abdomen. — Stomach,  of  ordinary  dimensions;  its  lining 
membrane,  of  a  bluish  grey  color,  except  in  the  small  curva- 
ture, where  for  about  one  inch  and  a  lialf,  it  was  of  a  pale 
pink  tint  ;  thickness  and  consistence  every  where  natural,  ex- 
cept a  very  limited  portion  in  the  great  curvature,  which  was 
softened  and  easily  torn  ;  there  was  over  its  whole  sui-face  a 
layer  of  thick,  tenacious  mucus.  The  mucous  membrane  of 
the  small  intestine  was  sprinkled  with  numerous  black,  minute 
points  ;  in  other  respects  healthy.  That  of  the  large  intestine 
was  soft  as  mucus,  pale  in  the  upper  half,  a  little  red  in  the 
lower,  without  ulcerations,  and  in  contact  with  a  turbid,  grey- 
ish-pink substance.  The  mesentery  and  other  viscera  of  the 
abdomen  were  healthy. 

364.  Although  in  our  description  of  the  lateral  ventricles, 
we  have  neglected  to  describe  the  state  of  the  lining  mem- 
brane, yet  the  nature  of  the  contents  seems  to  me  sufficiently 


310  SYMPTOMS.  —  cerebral;      [Part  II, 

to  justify  the  idea  that  it  was  inflamed  ;  the  fever  also  and  the 
cerebral  symptoms  can  scarcely  be  referred  to  any  other 
lesion.  The  latter  were  in  fact  those  of  arachnitis  ;  and  we 
ought  to  remark  that  the  weakness  of  the  patient  seemed  to 
be  no  obstacle  to  their  development.  It  is  true  that  a  very 
important  symptom,  viz.,  headache,  was  absent  ;  (at  least  the 
patient  never  complained  of  pain  in  his  head)  ;  but  this  might 
be  owing  to  the  rapid  progress  of  the  disease,  which  was  fatal 
in  forty-eight  hours  ;  its  different  periods  were  confounded 
together,  and  delirium  with  slight  drowsiness,  were  the  first 
indications  of  its  existence.  We  have  already  seen  that  the 
progress  of  inflammations  occurring  towards  the  close  of 
chronic  diseases,  or  when  debility  is  far  advanced,  is  rapid  ; 
and  of  this  the  present  observation  furnishes  an  additional 
proof.  It  is  also  remarkable  that  the  alteration  of  the  arach- 
noid was  limited  to  the  portion  of  this  membrane  lining  the 
lateral  ventricles,  which,  in  the  opinion  of  those  authors  who 
have  most  successfully  studied  this  disease  (Messrs.  Parent 
and  Martinet),  is  extremely  rare.* 

365.  As  to  the  origin  of  the  tuberculous  affection  of  the 
lungs,  it  was  probably  coincident  with  that  of  the  cough  ;  but 
of  this  we  cannot  be  positive.  What  appears  certain  is,  that 
the  progress  of  the  disease  was  extremely  slow.  This  is  prov- 
ed both  by  the  mildness  of  the  symptoms  and  the  undimin- 
ished strength,  until  the  appetite  began  to  fail. 

366.  The  following  observation  is  an  example  of  partial 
softening  of  the  brain,  with  inflammation  of  a  small  portion  of 
the  sub-arachnoidean  tissue. 

*  Andral.  in  his  Clin.  Med.,  vol.  iv.  page  65,  relates  five  cases  of  this  de- 
scription, only  three  of  which  are  distinctly  inflammatory.  Out  of  eighty- 
nine  cases  of  arachnitis  (vide  pages  201,  203),  in  eleven  the  a/Iëclion  vs^as 
confined  to  the  ventricles.  —  Cowan. 


Chap.  7.]    SOFTENING  or  THE  BRAIN  ;    SUB-ARACHNITIS.    311 


TWENTY-FIFTH     OBSERVATION. 

A  butcher's  man,  set.  38,  short,  but  stoutly  made,  with  black 
hair,  and  brown  skin,  and  of  a  strong  constitution,  had  been  ill 
eight  months  when   he   entered   the   hospital  of  La  Charité, 
September  Ist,  1822.     Usually  in   good  health,   he   had  not 
been  liable  to  cold   or  sore  throat  ;  he  attributed  his  present 
illness  to  a  violent  blow  he  had  received   on   his  chest  shortly 
before  the  appearance  of  the   first  symptoms.     At  the  com- 
mencement there  was  cough,  with  somewhat  copious  expec- 
toration, and  alternation   of  heat  and   cold  ;  these  symptoms 
continued,  but  after  two  months  the  rigors  almost  ceased  ;  he 
had  only  perspired  the  last  fifteen  days.     The  cough  was  gen- 
erally violent,  and  the  voice  had  been  affected  after  the  second 
month.     At  this   period   also  he   was   attacked  with  a  pretty 
copious  haemoptysis  ;  this  was  afterwards  renewed,  but  small 
in  quantity,  and  at  distant  intervals.     The  appetite  gradually 
diminished,  and  for  the   last  three   days  the   stools   had  been 
liquid,  which  he  attributed  to  having  eaten  a  large  quantity  of 
grapes.     His  strength  failed,   and   for  three   months   he  had 
ceased  his  usual  occupations,  though  he  had  never  been  con- 
fined to  his  bed.     September  2d.  No  headache  ;  cough,  not 
frequent  ;  sputa,  greenish,  opaque,  most  of  them  floating  in  a 
clear  fluid  ;  voice,  rough  ;  percussion  of  the  chest,   clear  on 
both  sides  ;  a  crepitating  râle   with  obscure   respiration  under 
the  right  clavicle,  without   pectoriloquy.     Pulse,  calm  ;  heat, 
natural  ;    tongue,  clean  ;    little  appetite  ;    deglutition,   easy  ; 
stools,  liquid,  not  numerous.     No   pain   either  in   the  throat, 
larynx  or  abdomen. 


312  ssMPTOMs.  —  CEREBRAL  ;  [Part  11, 

(Rice  water  ;  gum  potion  ;  a  quarter  of  the  house  allow- 
ance). 

But  little  change  occurred  on  the  following  days.  28th. 
Still  no  headach  or  pains  in  the  limbs  ;  percussion  under  right 
clavicle  dull,  whh  very  obscure  respiration,  and  more  copious 
crepitation  than  before.  Considerable  resonance  of  the  voice  in 
the  corresponding  point  posteriorly  ;  the  anorexia  and  loose- 
ness had  increased  ;  there  was  a  bad  taste  in  the  mouth,  and 
pain  in  the  epigastrium  ;  this  pain  had  lasted  three  days,  and 
on  the  previous  evening  the  patient  had  vomited  a  little  bile. 
He  complained  of  a  twisting  sensation  in  the  hypogastrium, 
and  the  abdomen  was  tympanitic. 

(Rice  water  sweetened  with  quince  syrup  ;  diascordium  ; 
gum  potion;  five  cups  of  soup). 

From  this  moment  the  debility  rapidly  increased,  and  the 
patient  no  longer  left  his  bed  ;  he  often  complained  to  his 
companions  of  constant  headache,  and  frequently  supported 
his  head  with  his  hands.  In  the  night  of  the  9th  of  October, 
there  were  alternations  of  stupor  and  delirium  ;  persistence  of 
the  same  symptoms  the  next  day  and  following  night. 

On  the  11th,  at  the  hour  of  visit,  he  did  not  answer,  or  re- 
plied very  indistinctly  to  questions  ;  his  eyes  were  usually 
fixed,  and  at  moments  there  was  a  smile  on  his  lips  ;  the  res- 
piration was  slightly  accelerated  ;  pulse,  calm,  at  sixty-six. 
The  delirium  continued,  and  the  increased  agitation  compelled 
the  use  of  a  straight  waistcoat. 

The  next  day,  his  expression  was  nearly  natural  ;  intelligence 
had  returned,  and  he  went  alone,  without  falling  or  stumbling, 
to  the  night-stool.  During  the  night,  constant  delirium  but 
no  agitation.  13th.  The  same  state  ;  heat,  elevated  ;  pulse, 
frequent.  The  patient  did  not  speak.  14th.  He  again  rose 
to  go  to  the  night-stool,  but  at  the  visit  he  appeared  quite 


Chap.  7.]    SOFTENING  OF  THE  BRAIN  ;  SUB-ARACHNITIS.    313 

exhausted,  though  in  answer  to  questions  he  said  he  was  quite 
well.  During  the  day  he  showed  by  signs  that  he  understood 
what  was  said  to  him  but  was  unable  to  speak.  15tli.  Expres- 
sion rather  animated;  eyes,  half  closed  ;  lay  with  the  knees 
elevated  ;  made  us  understand  that  he  did  not  suffer  pain. 
16th.  Retained  the  [same  position  in  bed  as  he  had  the  pre- 
ceding evening;  he  seemed  perfectly  conscious,  followed  our 
movements  with  his  eyes,  and  at  nine,  a.  m.,  expired. 

O'pening  of  the  corpse  iwenty-tivo  hours  after  death. 

Exterior.  —  Extreme  emaciation. 

Head,  —  Dura  mater  as  if  lacerated,  giving  passage  to  the 
arachnoidean  granulations  ;  marked  distention  of  the  superior 
veins  on  the  right  side  ;  very  little  on  the  left.  Three  spoons- 
ful of  serum  in  the  left  lateral  ventricle,  much  less  in  the 
right  ;  septum  lucidum  softened,  pulpy,  of  natural  color. 
Similar  state  of  the  posterior  crura  of  the  fornix  ;  corpus  cal- 
losum  less  consistent  than  the  other  portions  of  the  brain,  but 
it  was  by  no  means  so  soft  as  the  septum.  The  rest  of  the 
encephalon  was  firmer  than  usual,  and  very  slightly  injected. 
Between  the  arachnoid  and  pia  mater,  anterior  to  and  at  the 
sides  of  the  optic  nerves,  there  was  a  layer  of  concrete  pus, 
about  three  lines  thick  and  an  inch  wide. 

Neck.  — A  superficial  ulceration  on  the  inferior  surface  of 
the  epiglottis  ;  larynx,  natural  ;  two  inches  lower  down,  and 
on  the  fleshy  potion  of  the  trachea,  there  was  an  ulceration 
about  the  size  of  a  half  dollar,  with  thickening  of  the  corres- 
ponding submucous  tissue  ;  in  other  respects  the  mucous  mem- 
brane was  healthy. 

Thorax.  —  Weak  cellular  adhesions  over  the  summit  of 
the  left  lung,  which  presented  a  moderate  quantity  of  tuber- 
p  2 


314  SYMPTOMS. — cerebral;       [Part  II, 

cles,  and  of  grey,  semi-transparent  granulations,  diminishing  in 
size  and  number  from  above  downwards  ;  its  lower  lobe  was 
firm,  granulated,  of  a  variable  red  color,  and  everywhere  hep- 
atized.  The  right  lung  adhered  to  the  costal  pleura  through- 
out, and  very  firmly  at  Its  apex  ;  it  offered  in  its  upper  lobe  a 
vast  tuberculous  excavation  communicating  with  the  bronchia 
and  with  other  smaller  cavities  ;  all  of  these  contained  a  great 
quantity  of  sanious  matter  ;  they  were  lined  by  two  false  mem- 
branes, one  of  which  was  soft  and  yellowish,  the  other  very  firm, 
greyish,  semi-cartilaginous,  lying  either  on  the  healthy  lung, 
the  grey,  semi-transparent  matter  or  tubercles.  In  the  re- 
mainder of  the  same  lobe  there  were  numerous  softened  tuber- 
cles, or  some  more  or  less  excavated  ;  its  lower  lobe  was  of  a 
deep  red  color  and  carnified.     Heart  and  aorta,  natural. 

Abdomen.  —  Stomach,  rather  contracted  ;  its  lining  mem- 
brane covered  with  a  good  deal  of  mucus  ;  it  was  pale,  with 
a  punctated  injection  in  the  great  cul-de-sac  ;  its  consistence 
and  thickness  were  rather  less  than  natural.  There  were  a 
few  small  ulcerations,  and  four  submucous  abscesses,  about 
the  size  of  a  pea,  in  the  lower  six  feet  of  the  small  intestine; 
in  other  respects  the  mucous  membrane  was  healthy.  That 
of  the  caecum  and  colon  was  much  softened,  with  some  small 
ulcerations  in  the  right  colon.  Mesenteric  glands,  increased 
in  volume  with  no  other  alteration.  The  remaining  viscera 
were  healthy. 

367.  The  softened  state  of  the  septum  lucidum  and  fornix, 
with  the  inflammation  of  the  sub-arachnoidean  tissue  between 
the  optic  nerves,  renders  the  analysis  of  the  cerebral  symp- 
toms difficult  and  necessarily  throws  doubt  upon  any  classifica- 
tion we  may  make.  We  may,  however,  remark,  that  there 
were  neither  pains,  rigidity,  nor  paralysis  of  the  limbs,  and,  con- 


Chap.  7.]    SOFTENING  OF  THE  BRAIN;  SUB-ARACHNITIS.    315 

sequently,  but  very  incomplete  indications  of  softening.  The 
headache  and  agitation  may  be  equally  referred  to  the  one  alter- 
ation as  to  the  other,  so  that  it  is  impossible  to  decide  whether 
they  were  owing  to  these  two  species  of  lesions,  or  to  one  of 
them  only.  The  general  characters  of  the  symptoms,  how- 
ever, were  rather  those  of  meningitis  than  those  of  partial 
softening  of  the  brain. 

Without  insisting  farther  on  this  subject,  which  is  not  im- 
portant for  our  immediate  purpose,  let  us  observe  that  there 
was  hepatization  of  the  left  lung,  and  that  its  inflammation,  as 
is  so  frequently  the  case  when  complicated  with  a  cerebral 
affection,  gave  rise  to  no  symptom  ;  that  the  ulcerations  of  the 
trachea  and  epiglottis  were  also  latent  ;  and  what  is  still  less 
frequently  the  case,  that  there  had  been  hoarseness  v/ith  alter- 
ation of  the  voice  for  more  than  six  months,  while  the  state 
of  the  larynx  was  healthy. 

368.  We  shall  conclude  this  chapter  with  a  rapid  summary 
of  an  observation  already  published,*  which  is  an  example  of 
partial  softening  of  the  brain  unaccompanied  by  any  other 
alteration. 


TWENTY-SIXTH     OBSERVATION. 

A  WATCHMAKER,  ffit.  19,  of  dclicate  health  and  very  nerv- 
ous temperament,  entered  the  hospital  of  La  Charité,  Oc- 
tober 29th,  1823.     He  had  coughed   and   expectorated  the 

*  Mémoire  sur  le  Ramollissement  avec  Amincissement  de  la  Membrane 
Muqueuse  de  V Estomac.  Vide  Mémoires  sur  diverses  maladies,  page  31. 
—  Louis. 


316  SYMPTOMS.  CEREBRAL  J         [Part  11, 

last  four  months,  was  extremely  emaciated,  and  presented  all 
the  symptoms  of  phthisis  ;  he  complained  of  a  dull  headache, 
with,  pains  in  the  limbs  and  loins,  vigilium,  and  extreme  de- 
bility. His  intellect,  naturally  good,  was  unaffected,  and  his 
expression  was  without  any  peculiarity  save  the  emaciation. 

Nothing  remarkable  occurred  on  the  two  following  days,  but 
on  the  2d  of  November  there  was  a  great  general  prostration 
of  strength  ;  he  did  not  reply  to  questions,  although  he  indi- 
cated by  signs  that  he  comprehended  them.  He  could  not 
support  himself  in  the  upright  posture.  Tiie  same  night  there 
were  delirium  and  constant  talking.  3d.  At  ten,  a.  m.,  his 
eyes  were  fixed  ;  expression,  dull  ;  limbs,  on  both  sides  very 
feeble,  almost  incapable  of  any  movement  ;  he  understood 
when  spoken  to,  but  replied  with  the  greatest  difficulty  and 
unwillingness,  so  that  it  was  only  after  repeated  questions  that 
he  said  that  he  had  a  pain  in  his  head.  During  the  day  the 
state  of  the  stupor  was  complete,  without  convulsive  move- 
ments. On  the  next  day,  4th,  spasmodic  contractions  of  the 
limbs,  principally  those  of  the  right  side  ;  pupils,  dilated, 
especially  that  of  the  left  eye  ;  head,  turned  to  the  left  ;  total 
loss  of  consciousness  with  an  expression  of  vacancy.  The  pulse, 
which  was  ninety-four  in  the  evening,  was  now  one  hundred 
and  fourteen  ;  frequent  moaning  during  respiration.  These 
symptoms  continued  until  the  evening,  when  he  expired  at 
eight  o'clock. 

Opening  of  the  corpse  thirty-six  hours  after  death. 

Head.  —  Lacerations  of  the  dura  mater  traversed  by  gran- 
ulations attached  to  the  arachnoid,  which  was  thickened  and 
opaque  in  the  corresponding  points.  Cerebral  veins,  rather 
distended,  with  some  injection  of  the  pia  mater;  the  right 
hemisphere,   firm  and  with   numerous  red   points  ;    the   left, 


Chap.  7.]    SOFTENING  OF  THE  BRAIN  ;  SUB-ARACHNITIS.    317 

less  injected,  rather  soft  ;  septum  lucidum,  of  a  pulpy  consist- 
ence ;  a  similar  state  of  the  fornix,  particularly  of  the  left 
pillar,  without  any  change  of  color  ;  two  spoonsful  of  serous 
fluid  in  the  left  ventricle,  rather  less  in  the  right  ;  in  the  former 
the  lining  membrane  was  thickened.  Two  spoonsful  of  serous 
fluid  also  in  the  inferior  occipital  fossœ. 

Thorax. — Some  tubei'culous  excavations  in  the  summit 
of  the  left  lung,  the  anterior  part  of  which,  for  the  space  of 
two  inches,  almost  wholly  consisted  of  tubercles  and  the  grey, 
semi-transparent  matter. 

Abdomen.  —  Mucous  membrane  of  the  stomach,  softened 
and  thinned  over  a  considerable  extent.  Some  ulcerations  in 
the  small  intestine.  Very  considerable  softening  of  the  mu- 
cous membrane  of  the  colon. 

369.  The  softening  of  the  septum  lucidum  and  fornix  were 
very  similar  to  what  existed  in  the  preceding  observation  ; 
the  effusion  into  the  ventricles  coincided  in  its  quantity  with 
the  difference  in  the  degree  of  softening  existing  on  one  side 
and  the  other,  which  makes  us  consider  it  as  an  effect,  and  not 
a  complication.  Besides,  the  symptoms  were  here  very  dis- 
tinct, viz.,  headache,  delirium,  pain,  spasmodic  contraction  of 
the  limbs,  and  lastly,  dilated  pupils.  We  were  unable  to  de- 
cide whether  there  was  any  paralysis  of  the  extremities,  but 
it  is  very  probable  that  there  was  some,  and  that  It  came  on 
soon  after  that  of  the  retina,  which  was  marked  by  the  dilata- 
tion of  the  pupils.  The  extreme  debihty  of  the  patient  when 
the  affection  commenced,  and  its  subsequent  rapid  progress 
with  the  intense  nature  of  the  symptoms,  are  all  very  remark- 
able. 

370.  We  have  elsewhere  detailed  (Obs.  15),  the  history  of 
a  partial  softening  of  the  cerebral  substance,  preceded  by  the 


318       SYMPTOMS.  LATENT  PHTHISIS,    IST  KIND  ;    [Part  II, 

inflammation  of  the  sub-arachnoidean  tissue  on  the  upper  por- 
tion of  the  brain,  and  which  had  come  on  thirty  days  before 
death.  Although  not  intense,  the  symptoms  corresponding  to 
both  of  these  lesions  were  very  distinct. 

371.  We  would  remark,  in  terminating  this  division  of  our 
subject,  that  we  have  observed  partial  softening  of  the  brain 
quite  as  frequently  after  other  chronic  affections  ;  that  we  have 
never  seen  apoplexy  come  on  at  the  close  of  diseases  of  long 
duration  ;  that  this  fact  makes  an  additional  distinction  be- 
tween softening  of  the  brain  and  apoplexy  ;  and  it  points  out 
a  fresh  analogy  between  haemorrhage  of  the  brain  and  that  of 
other  organs,  which  so  seldom  occurs,  in  any  of  them,  when 
the  debility  is  extreme. 


CHAPTER    VIII. 

OF    THE    VARIETIES    WHICH    PHTHISIS    PRESENTS    IN    ITS 
PROGRESS. 

372.  In  the  general  description  of  phthisis,  we  have  seen 
that  its  first  symptoms  are  cough,  expectoration,  dyspnoea, 
and  sometimes  haemoptysis  ;  that  sputa  do  not  always  com- 
mence with  the  cough  ;  that  the  dyspnoea  is  equally  irregu- 
lar as  to  the  time  of  its  appearance  ;  this  is  also  true  in  regard 
to  the  fever  and  the  succeeding  symptoms.  These  slight 
differences,  however,  in  the  order  and  duration  of  the  morbid 
phenomena,  do  not  interfere  with  the  regular  progress  of  the 
disease  ;  they  do  not,  if  we  may  so  express  ourselves,  alter  its 
physiognomy  ;  but  there  are  instances  where  its  characters  are 
so  completely  modified  that  its  recognition  is  impossible  before 


Chag.  8.]  MAY    BE    SUSPECTED    TO    EXIST.  319 

its  progress  is  considerable  ;  it  is,  in  fact,  latent^  for  a  longer  or 
shorter  period.  At  other  tinnes  it  assumes  the  form  and  pro- 
gress of  acute  diseases  ;  its  different  periods  seem  confounded 
together,  and  the  diagnosis  is  not  less  obscure  than  in  the 
previous  case.  We  shall  successively  study  these  two  varie- 
ties of  phthisis,  adducing  facts  to  establish  their  existence.     . 


ARTICLE    1, 


LATENT   PHTHISIS. 


TWENTY-SEVENTH     OBSERVATION. 

373.  A  WOMAN,  aet.  32,  with  active  intelligence  and  good 
memory,  of  middle  stature  and  pretty  strong  constitution,  was 
admitted  into  the  hospital  of  La  Charité,  November  9th, 
1822.  She  was  not  liable  to  colds,  had  been  ill  three  years, 
but  considerably  worse  the  last  two  months  and  a  half.  Her 
illness  had  commenced  with  rigors,  followed  by  heat  and  per- 
spiration, and  until  the  last  three  months  they  had  been  re- 
peated daily  at  about  one  o'clock.  The  appetite  had  dimin- 
ished from  the  beginning  ;  the  thirst  had  become  urgent,  and 
there  was  slight  emaciation.  No  other  symptoms  were  ob- 
served during  the  first  year.  At  the  commencement  of  the 
second  she  began  to  cough  and  expectorate  clear  sputa,  which 
during  the  last  three  months  have  become  opaque  and  num- 
raulated.  She  had  kept  her  bed  nine  weeks,  and  had  had 
slight  diarrhœa  the  last  four,  before  entering  the  hospital. 

November  10th.  Mind  and  senses,  perfect;  extreme  ema- 

*  Some  speculative  objections  have  been  made  to  the  use  of  the  term 
latent,  when  applied  to  plithisis.  It  is  evident  that  our  author  employs  it 
merely  to  indicate  the  obscurity  of  the  symptoms.  —  Cowaw. 


320        SYMPTOMS.  LATENT  PHTHISIS,   1  ST  KIND  ;    [Part  II, 

elation  ;  breathing,  rather  accelerated  ;  cough,  not  frequent  ; 
sputa,  nummulated,  of  a  dirty  pink  color,  and  soon  losing 
their  shape.  Percussion,  dull  under  the  clavicles,  particularly 
under  the  left,  and  over  a  considerable  space  ;  tracheal  respi- 
ration and  evident  pectoriloquy  in  the  same  points  ;  this  was 
also  the  case  in  the  corresponding  parts  posteriorly.  Pulse, 
small,  weak,  regular,  frequent  ;  heat,  natural  during  the  day, 
elevated  at  night  ;  perspirations  confined  to  the  head  and 
chest  ;  tongue,  natural  ;  mouth,  clammy  ;  thirst,  not  urgent  ;  no 
appetite  ;  deglutition,  difficult  ;  she  had  experienced  a  sense  of 
heat  and  dryness  of  the  throat  the  last  two  months  ;  abdomen, 
a  little  sensible  to  pressure  ;  the  previous  evening  three  mucous 
stools.     Great  debility. 

(Decoction  of  rice  with  quince  syrup  ;  three  cups  of  in- 
fusion of  catechu  with  the  same  syrup  ;  gum  potion  ;  two  rice 
creams.) 

No  evident  change  took  place  on  the  following  days,  and 
on  the  18th  of  the  same  month,  after  an  agony  of  some  hours, 
she  expired. 

Opening  of  the  corpse  forty-eight  hours  after  death. 

Exterior.  —  Nothing  remarkable. 

Head.  —  Arachnoid,  thickened  and  rather  opaque  for  about 
two  inches  near  the  longitudinal  fissure,  with  partial  adhesions 
to  the  dura  mater  ;  some  slight  sub-arachnoidean  infiltration  ; 
two  small  spoonsful  of  fluid  in  each  lateral  ventricle  ;  that 
in  the  right  was  turbid. 

Neck.  —  The  epiglottis,  larynx  and  trachea  were  not  ex- 
amined. 

Thorax.  —  Strong  cellular  adhesions  over  the  summit  of 
the  right  lung  ;  the  left,  perfectly  free.  In  both  lungs  the 
upper  lobe  was  very  easily  broken,  and   presented  numerous 


Chap.  8.]  MAT   BE    SUSPECTED    TO    EXIST.  321 

small  excavations,  communicating  with  each  other,  and  lined 
by  a  false  membrane  ;  their  intervals  consisted  of  grey,  semi- 
transparent  granulations,  and  small  portions  of  hepatized  lung. 
The  lower  lobes  were  healthy.  Heart,  of  natural  volume  ; 
sides  of  the  left  ventricle,  rather  thin,  those  of  the  right,  evi- 
dently thickened  ;  both  were  of  tolerable  consistence  ;  the 
aorta  was  of  a  rose  tint  here  and  there,  without  other  alter- 
ation. 

Abdomen.  —■  Stomach,  of  natural  volume  ;  lining  mem- 
brane, pale,  without  lividity,  and  of  normal  thickness  and 
consistence  ;  duodenum,  healthy.  In  the  lower  half  of  the 
small  intestine  there  were  some  granulations  of  a  tuberculous 
nature  ;  many  of  them  vœre  slightly  ulcerated  ;  over  others, 
which  were  not  softened,  the  mucous  membrane  was  healthy. 
That  of  the  large  intestine  was  a  little  softened  near  the  cae- 
cum, where  it  presented  ten  small  ulcerations,  from  one  to 
two  lines  in  diameter,  without  tubercles  ;  no  other  altera- 
tion. The  mesentery  and  other  viscera  of  the  abdomen  were 
healthy. 

374.  The  history  of  this  disease  presents  tv^70  very  distinct 
periods.  In  the  first,  there  was  febrile  movement,  without 
cough  ;  in  the  second,  the  fever  was  accompanied  with  cough 
and  expectoration.  Was  phthisis  present  in  the  first,  or  did 
it  originate  only  in  the  second  ?  If  the  examination  after  death 
had  revealed  a  chronic  and  serious  alteration  of  some  organ 
besides  the  lung,  we  might  attribute  to  it  the  symptoms  of  the 
first  period  ;  but  the  lungs  were  here  the  only  organs  seriously 
affected,  and  we  must,  consequently,  refer  the  symptoms  of 
both  periods  to  them,  more  especially  as  the  character  of  the 
febrile  movement  was  identical  in  both  ;  and  since  the  fever 
B  2 


322         SYMPTOMS.  LATENT  PHTHISIS,  IST  KIND;    [Part  II, 

was  not  preceded  by  bronchitis,  the  present  observation  will 
allow  us  to  draw  the  double  conclusion,  that  tubercles  may  be 
developed  in  the  lungs  independently  of  bronchitis,  and  that 
they  may  remain  latent  for  a  considerable  period,  that  is,  with- 
out exciting  either  cough  or  expectoration. 

375.  Another  fact  also  increases  the  interest  of  this  obser- 
vation, we  refer  to  the  gradual  diminution  of  appetite  during 
three  years,  although  the  gastric  mucous  membrane  presented 
no  perceptible  alteration.  This  is  a  striking  illustration  of  the 
fact  to  which  we  have  frequently  alluded,  that  a  lesion  of  a 
function  may  be  prolonged  during  a  considerable  time,  without 
the  presence  of  any  appreciable  organic  change  ;  that  loss  of 
appetite  is  not  enough  to  characterise  gastritis  ;  that  fever, 
and  by  this  we  mean  a  quick  pulse,  ^increased  heat,  &c.,  is  of 
itself,  vi'hatever  may  be  its  cause,  capable  of  producing  the 
same  result. 

Lastly,  this  observation  is  one  of  those  very  rare  instances 
in  which  the  development  of  tubercles  is  confined  to  the  supe- 
rior pulmonary  lobes. 


TWENTY-EIGHTH    OBSERVATION. 

376.  A  BELLOWS  mender,  ast.  44,  born  of  parents  who 
lived  to  an  advanced  age,  of  a  moderately  strong  constitution, 
with  a  fair  skin,  black  hair,  and  usually  enjoying  good  health, 
was  admitted  into  the  hospital  of  La  Charité,  March  24th, 
1824.  His  appetite  was  never  very  great  ;  his  habits  were 
very  temperate,  and  he  said  that  he  had  been  ill  the  last  nine 


Chap.  8.]  MAY    BE    SUSPECTED    TO    EXIST.  323 

months.  At  the  commencement  he  was  seized  with  rigors, 
followed  by  heat  and  perspiration,  thirst,  anorexia,  &£c.  ;  dur- 
ing  the  first  fortnight  the  fever  confined  him  to  his  bed,  after 
which  it  diminished,  though  it  never  was  completely  absent, 
as  he  was  always  liable  to  increased  heat  and  occasional  rigors  ; 
the  thirst  abated  ;  the  appetite  improved,  though  it  was  never 
quite  restored  ;  he  engaged  again  in  his  business,  and  contin- 
ued in  a  doubtful  state  of  health  for  four  months,  during  which 
time  there  was  no  cough.  After  this  period,  the  fever  con- 
tinued, the  rigors  returned  daily,  general  weakness  increased, 
and  he  was  obliged  to  relinquish  his  occupation,  and  lie  a  con- 
siderable part  of  the  day  on  his  bed.  In  the  last  six  weeks 
the  anorexia  was  complete,  and  shortly  afterwards  it  was  ac- 
companied with  a  slight  cough,  so  that  when  the  patient  en- 
tered this  had  been  present  about  a  month  only.  Our  inquiries 
were  particularly  directed  to  the  accuracy  of  this  fact,  and  the 
patient  invariably  persisted  in  declaring  that  he  never  had  any 
cough  previous  to  this  period.  For  some  months  he  had 
been  subject  to  hoarseness  and  oppression,  had  rapidly  lost 
his  flesh,  experienced  occasional  pains  between  the  shoulders, 
and  during  the  last  three  years  had  been  attacked  with  ten 
copious  haemoptyses,  one  of  which  occurred  only  a  few  days 
previous  to  his  entering  the  hospital. 

March  25th.  Expression,  natural;  sleep,  much  interrupted 
by  cough  ;  sputa,  yellow,  greenish,  not  nummulated,  but  con- 
tained in  a  limpid,  copious  fluid  ;  percussion  of  the  thorax, 
clear  ;  a  crepitating  râle  over  nearly  all  the  chest,  decreasing 
in  force  fiom  above  downwards;  tracheal  respiration,  with 
distinct  pectoriloquy  between  the  shoulders  ;  and  on  the  right 
side,  when  the  patient  spoke,  there  was  a  specious  of  metallic 
tinkling  ;  pulse  regular,  very  slightly  accelerated,  weak  ;  tongue, 
moist  and  clean,  pale  on  the  edges,  spotted  with  red  in  the 


324     SYMPTOMS. —  LATENT  PHTHISIS  ;  1  ST  KIND;    [Part  U, 

centre  ;  mouth,  clammy  ;  thirst,  moderate  ;  very  little  appe- 
tite ;  breath,  faetid  ;  constipation  the  last  two  days  ;  abdomen, 
every  where  yielding  and  free  from  pain. 

April  1st.  State  of  the  patient,  nearly  the  same  ;  he  com- 
plained of  constipation  and  extreme  weakness  ;  the  metallic 
tinkling,  more  evident  than  before  ;  anteriorly  on  the  right 
side  there  was  a  crepitating  râle  mingled  with  a  gurgling 
sound  ;  percussion,  dull  under  the  left  clavicle  ;  sense  of  op- 
pression in  the  epigastrium.  2d.  Uneasiness  and  anxiety, 
with  increased  dyspnœa.  These  symptoms  gradually  in- 
creased, and  the  patient  expired  the  following  morning,  at 
five  o'clock. 

Opening  of  the  corpse  twenty-seven  hours  after  death. 

Exterior.  —  Nothing  worth  noting. 

Head.  — Rather  considerable  sub-arachnoidean  infiltration; 
some  granulations  near  the  longitudinal  fissure,  adhering  to 
the  dura  mater  ;  pia  mater,  slightly  injected  ;  brain,  firm  and 
healthy  ;  two  spoonsful  of  serum  in  the  lateral  ventricles. 

Neck.  —  Epiglottis,  larynx  and  trachea,  natural. 

Chest.  —  Lungs,  every  where  adherent  to  the  costal  pleu- 
ra ;  superiorly  the  adhesions  consisted  of  a  very  dense  false 
membrane,  a  line  thick,  and  lower  down,  of  cellular  prolonga- 
tions. The  summit  of  the  left  lung  presented  a  vast,  rugged 
excavation,  traversed  by  bands,  and  lined  by  a  false,  semi- 
cartilaginous  membrane,  lying  upon  more  or  less  serious- 
ly diseased  lung.  The  upper  lobe  was  indurated,  of  a 
greyish  color  over  two  thirds  of  its  extent,  from  its  anterior 
edge  ;  it  had  a  granulated  appearance  internally  ;  it  was,  in 
fact,  hepatized  and  easily  broken  down  ;  it  contained  numer- 
ous tubercles  and  some  grey,  semi-transparent  matter;  the 


Chap.  8.]  MAY    BE    SUSPECTED    TO    EXIST.  325 

lower  lobe  was  rather  red,  with  pretty  numerous  tubercles 
and  granulations.  A  similar  excavation  existed  at  the  summit 
of  the  right  lung,  but  still  larger  ;  the  remainder  of  the  upper 
lobe  consisted  of  tubercles  and  grey  granulations.  The  bronchia 
communicating  with  the  two  large  cavities  were  very  red  and 
much  thickened  ;  the  others  were  thin  and  of  a  pale  pink 
color.     Heart  and  aorta,  natural. 

Abdomen.  —  Stomach,  of  moderate  volume,  containing  a 
good  deal  of  thick  and  tenacious  mucus.  The  lining  mem- 
brane was  rather  red  round  the  cardiac  orifice,  greyish  along  the 
large  curvature,  white  in  other  parts  ;  it  was  a  little  softened 
in  the  great  cul-de-sac,  of  normal  consistence  and  thickness 
elsewhere.  That  of  the  small  intestine  presented  some  varia- 
bly red  spots,  and  in  the  lower  half  five  small  ulcerations, 
many  of  which  contained  tuberculous  granulations  in  their 
centres.  There  were  three  large  ulcerations  in  the  caecum  ; 
the  mucous  membrane  of  the  colon  was  here  and  there  of  a 
light  red,  without  any  other  alteration  ;  the  fœces  were  of  a 
bright  yellow  color,  of  normal  form  and  consistence.  Mesen- 
teric glands,  rather  voluminous,  of  natural  color  and  firmness. 
Liver,  pale  ;  bile  in  the  gall-bladder,  dark  colored  and  thick, 
like  treacle.     The  other  abdominal  viscera  were  healthy. 

377.  Between  this  and  the  foregoing  observation  there  is  an 
almost  complete  analogy  both  as  regards  the  simplicity  of  the 
disease  and  the  progress  of  the  symptoms.  The  febrile  move- 
ment preceded  the  cough,  which  indeed  only  existed  the  last 
six  weeks,  and  after  death  the  lungs  were  the  only  organs  in 
which  a  serious  and  chronic  lesion  was  present.  We  cannot, 
therefore,  attribute  the  previous  febrile  movement  either  to 
the  cough,  or  to  the  morbid  condition  of  any  other  viscus,  and 
we  are  forced  to  the  conclusion  that  tubercles  existed  Ions:  an- 


326        SYMPTOMS. LATENT  PHTHISIS,    1  ST  KIND  ;    [Part  II, 

terior  to  the  cough,  and  were  not  dependant  on  bronchitis. 
This  induction  is  still  more  natural  and  necessary  in  this  last 
observation  than  in  the  preceding,  for  in  this  the  cough  only 
dated  six  weeks,  while  the  tuberculous  excavations  were  very 
large,  and  we  have  already  seen  (19),  and  shall  again  verify 
the  fact  farther  on,  when  speaking  of  acute  phthisis,  that  sim- 
ilar excavations  are  not  produced  in  six  weeks,  or  in  two 
months,  that  they  necessarily  suppose  the  duration  of  the  dis- 
ease to  have  been  from  four  to  five  months. 

378.  In  both  cases  it  is  clear  that  tubercles  existed  in  the 
lungs  during  a  longer  or  shorter  space  of  time,  without  deter- 
mining cough  ;  that  they  gave  rise,  while  in  this  latent  state, 
to  febrile  symptoms  more  or  less  intense,  to  anorexia,  emacia- 
tion, and  more  or  less  complete  loss  of  strength.  In  cases 
where  these  are  the  only  symptoms,  are  we  able  to  decide 
upon  their  cause  ?  This  was  not  impossible  in  the  case  before 
us  ;  for  two  years  before  the  invasion  of  the  febrile  symptoms, 
the  patient  had  had  several  hœmoptyses,  and  we  have  said 
(233),  that  this  fact,  if  not  certain,  is  at  least  an  infinitely 
probable  indication  of  pulmonary  tubercles.  Supposing  for  a 
moment  that  we  had  seen  the  patient  soon  after  the  com- 
mencement of  the  fever,  we  ought  then,  by  means  of  the  pre- 
vious history,  to  have  suspected  the  existence  of  tubercles  in 
the  lungs,  and  perhaps  at  this  period  auscultation  would  have 
removed  every  doubt.  We  ought,  therefore,  never  to  neglect 
this  method  of  investigation,  whenever  febrile  symptoms  are 
present  without  any  evident  cause,  more  especially  if  these 
have  been  preceded  by  one  or  more  hœmoptyses.* 

*  I  cannot  forbear  attempting  to  impress  upon  the  mind  of  the  reader  the 
importance  of  this  paragrapli,  though  I  have  no  recorded  facts  to  support  it. 
But  I  remember  perfectly  the  case  of  a  female  who  entered  Louis's  wards 


Chap.  8.]  MAY    BE    SUSPECTED    TO    EXIST.  327 

379.  Among  the  stcondaiy  phenomena  meriting  attention, 
we  may  recall  the  metallic  tinkling,  which,  according  to  Laen- 
nec,  announces  a  vast  excavation  partly  filled  with  air  and 
fluid,  which  was  the  case  in  the  instance  before  us.  We  ought 
also  to  remember  the  state  of  the  gastric  mucous  membrane, 
which  was  almost  perfectly  healthy,  although  the  digestive 
functions  had  been  deranged  for  a  long  time.  However,  the 
absence  of  nausea  and  vomiting  did  not  lead  us  to  expect  any 
serious  alteration. 

Lastly,  the  bronchia  were  healthy  with  the  exception  of 
those  communicating  with  the  excavations,  proving,  as  we 
have  already  remarked  (36),  that  the  thickening  and  altera- 
tion of  their  mucous  membrane,  result  from  the  constant  action 
of  the  contents  of  the  excavations. 


TWENTY-NINTH     OBSERVATION. 

380.  A  SEMPSTRESS,  Bst.  22,  born  of  healthy  parents,  not 
liable  to  cold,  usually  in  good  health,  and  with  considerable 
embonpoint,  was  admitted  into  the  hospital  of  La  Charité 
September  9th,  1824.  She  had  been  subject  to  shortness  of 
breath  from  her  infancy,  and  her  present  illness  had  com- 
menced two  years  and  a  half  before  her  entrance  into  the  hos- 
pital.    During  the  first  seven  months  she  had  constant  fever, 

with  intense  febrile  excitement  and  some  dyspnœa.  The  case  was  a  very 
difficult  one,  and  very  rigid  examinations  were  made  in  order  to  discover 
some  local  disease.  The  respiration  was  indistinct,  but  presented  nothing 
peculiar  at  first.  After  a  time  an  expiration  came  on,  first  in  one  lung  and 
afterwards  in  the  other,  but  before  this  commenced,  the  fever  made  one  of 
us  (Jackson)  decide  that  it  was  a  case  of  acute  phthisis.  —  H.  I.  B. 


328     SYMPTOMS.  —  LATENT  PHTHISIS,  Istkind;  [Part  II, 

with  daily  paroxysms  of  cold  and  heat  at  four,  p.  m.  These 
gradually  ceased  without  any  treatment  having  been  tried. 
While  they  continued,  the  patient  was  confined  to  her  bed, 
ate  very  little,  having  almost  completely  lost  her  appetite 
from  the  commencement  ;  the  emaciation  was  rapid.  She 
afterwards  partially  recovered  her  strength  and  flesh  ;  her 
usual  dyspnœa  considerably  increased,  and  during  the  three 
months  which  preceded  her  entrance  into  the  hospital,  that  is, 
from  the  moment  she  began  to  cough  and  expectorate,  it  be- 
came extreme.  Previously  to  this  period  she  had  neither 
coughed  nor  expectorated,  and  on  this  point,  the  patient, 
whose  intelligence  was  developed  and  memory  good,  never 
varied  her  statement.  The  appetite  was  always  much  dimin- 
ished, almost  absent.  The  diarrhœa,  constant,  sometimes 
copious  during  the  last  eight  months,  and  accompanied  with 
colic  pains.  The  debility  daily  augmented,  and  for  five 
months  before  we  saw  her,  she  had  been  confined  to  her  bed. 
The  rigors,  followed  by  heat  and  perspiration,  had  re-appeared 
the  last  five  weeks  ;  there  had  been  no  hagmoptysis. 

September  10th.  Face,  pale  ;  extreme  weakness  ;  intel- 
lectual faculties,  perfect  ;  great  emaciation  ;  considerable  dys- 
pnœa ;  speaks  hurriedly  ;  cough,  principally  violent  in  the 
morning  ;  expectoration,  greenish,  scanty,  semi-opaque.  Tra- 
cheal respiration  with  distinct  pectoriloquy  and  dulness  of 
sound  to  an  extent  of  five  inches  under  the  left  clavicle  ;  the 
same  symptoms  posteriorly  in  the  corresponding  point  ;  on  the 
right  the  respiration  seemed  natural  ;  pulse,  weak  and  accel- 
erated ;  heat,  rather  elevated  ;  tongue,  rather  pale  ;  very  little 
appetite;  the  liver  extended  three  inches  below  the  ribs;  no 
pains  in  the  epigastrium  ;  three  stools  with  colic  the  last 
twenty-four  hours. 


Chap.  8.]  MAY    BE    SUSPECTED    TO    EXIST.  329 

(White  decoction  ;  solution  of  gum  syrup  ;  julep  ;  rice  and 
an  egg  for  food). 

12th.  She  complained  for  the  first  time  of  pains  in  the  up- 
per part  of  the  larynx.  18th.  Continuation  of  the  pains, 
which  were  only  felt  on  attempting  to  swallow  ;  appetite, 
rather  improved  ;  coughs  little  ;  no  rigors.  20th.  Increased 
cough  and  dyspnoea,  with  frequent  stools  and  copious  perspi- 
rations. 

(Gum  potion  with  a  grain  of  opium). 

The  diarrhœa  rapidly  diminished  ;  the  cough  was  occasion- 
ally violent  ;  some  nausea  and  even  vomitings  of  a  clear  fluid 
mingled  with  mucus  ;  total  loss  of  appetite  ;  no  alteration  of 
voice. 

30th.  The  pains  in  the  neck  had  ceased  ;  she  complained 
of  headache  and  general  lassitude:  the  tongue,  lips,  and  in- 
terior of  the  cheeks,  were  covered  by  a  large  number  of  white 
thin  patches,  beneath  which  the  mucous  membrane  was  rather 
redder  than  natural  ;  she  experienced  no  pricking  sensations 
in  the  tongue,  and  the  membranous  patches  disappeared 
the  next  day.  The  deglutition  became  very  difficult  ;  the 
expectoration  ceased  ;  the  pulse  fell  to  ninety  the  last  two 
days,  and  on  the  4th  of  October,  at  ten,  a.  m.,  she  expired, 
having  preserved  her  consciousness,  and  having  experienced 
much  mental  anxiety  at  the  idea  of  dying. 

Opening  of  the  corpse  tioenty-iwo  hours  after  death. 

Exterior.  —  Nothing  remarkable. 

Head. — Four  small  spoonsful  of  fluid  on  the  upper  por- 
tion of  the  arachnoid  ;  slight  sub-arachnoidean  infiltration  • 
some  injection  of  the  pia  mater  ;  cortical  substance,  of  a  pink 
color;  the  medullary  presented  few  red  points.  A  spoonful 
s  2 


330        SYMPTOMS.  • —  LATENT  PHTHISIS,    IST  KIND  ;    [Part  II, 

of  clear   fluid  in  each  lateral   ventricle;  two  more  in  the  in- 
ferior occipital  fossae. 

Neck.  —  Mucous  membrane  of  the  pharynx,  pale,  thick- 
ened, and  on  it  there  were  numerous  small  ulcerations,  from 
one  to  two  lines  in  diameter  ;  that  of  the  epiglottis  was  de- 
stroyed over  half  of  its  lower  surface.  Nothing  worth  noting 
in  the  larynx  and  trachea. 

Thoeax.  — The  left  lung  adhered  intimately  to  the  costal 
pleura;  the  upper  lobe  was  invested  by  a  false  semi-cartilagi- 
nous membrane,  from  a  line  to  a  line  and  half  thick,  which 
was  continuous  anteriorly  and  internally  with  another  less 
thick,  which  partially  covered  the  upper  lobe  on  the  right  side. 
In  the  summit  of  the  left  lung  there  was  a  vast  excavation 
with  very  thin  parietes  anteriorly,  bounded  inferiorly  by  a 
thin  rugged  septum,  dividing  it  from  another  cavity  seated  in 
the  posterior  edge  of  the  lower  lobe.  The  remainder  of  the 
upper  lobe  was  transformed  into  a  greyish  matter,  opaque,  not 
granulated,  and  which  was  traversed  by  a  great  number  of  white 
firm  bands,  which  seemed  at  first  view  continuous  with  the  semi- 
cartilaginous  covering  which  has  been  described.  In  the  midst 
of  these  there  was  rather  a  large  number  of  small  tuberculous 
cavities.  The  cavity  of  the  lower  lobe  was  of  moderate  size, 
it  contained  a  thick  liquid  of  a  livid  red  color,  and  it  was  trav- 
ersed as  was  that  of  the  upper  lobe,  by  a  great  number  of 
bands  of  grey  semi-transparent  matter.  In  the  remainder 
of  the  lower  lobe  there  were  considerable  masses  of  grey 
semi-transparent  matter,  interspered  with  the  numerous  whitish 
yellow  granulations.  The  intervening  tissue  was  healthy. 
At  the  summit  of  the  right  lung  there  were  some  small  exca- 
vations, and  every  where  numerous  granulations  or  masses  of 
grey,  semi-transparent  matter,  similar  to  those  in  the  left  lung; 
many  among  them  were  an  inch   wide  by  three  inches  long, 


Chap.  8.]  MAY    BE    SUSPECTED    TO    EXIST.  331 

and  were  spotted  with  white,  opaque,  miliary  points  ;  two-fifths 
of  the  lung  were  permeable  to  the  air.  Bronchia,  rather  red 
and  slightly  thickened  near  the  excavations  ;  elsewhere  they 
were  healthy.  Having  injected  the  pulmonary  artery,  we  found 
ramifications  in  the  healthy  parts,  very  few,  and  only  in  some  of 
the  grey,  semi-transparent  masses.  There  were  none  in  the 
grey,  opaque  substance  occupying  the  upper  lobe  of  the  left 
lung,  which  substance,  to  all  appearance,  was  the  result  of 
chronic  inflammation  (16).  Several  of  the  bands  traversing 
the  excavations  were  supplied  by  some  very  small  arterial 
ramifications.  Heart,  small  ;  parietes,  thin,  but  firm  ;  aorta, 
healthy,  narrow. 

Abdomen.  —  Stomach,  elongated,  nearly  covered  by  the 
liver  ;  its  mucous  membrane  was  of  a  bright  red,  rather  soft- 
ened anteriorly,  normal  every  where  else.  Some  minute 
ulcerations  in  the  lower  sixth  of  the  small  intestine,  and  in 
their  intervals  numerous  white,  opaque,  semi-cartilaginous 
granulations,  increasing  in  size  and  number  towards  the 
caecum  ;  in  the  rest  of  its  extent  the  mucous  membrane  was 
healthy,  with  the  exception  of  some  red  spots.  Eight  irreg- 
ular ulcerations,  from  an  inch  to  an  inch  and  a  half  in  surface, 
in  the  caecum,  ascending  and  transverse  colon.  The  corres- 
ponding mucous  membrane  was  destroyed,  and  the  cellu- 
lar layer  rough  and  thickened.  In  the  intermediate  spaces 
and  in  the  remainder  of  its  extent,  tlie  mucous  membrane  was 
a  little  softened,  of  twice  its  usual  thickness,  and  in  some 
points  of  a  violet  color.  Mesenteric  glands,  small  and  healthy. 
The  liver  descended  an  inch  and  a  half  below  the  ribs,  was  of 
a  tawny  color  spotted  with  red,  with  numerous  pale  points  ;  it 
was  not  distinctly  adipous.  The  bile  of  the  gall-bladder,  dark 
colored,  and  of  the  consistence  of  treacle.  Spleen,  rather 
voluminous  and  softened  ;  the  other  viscera,  healthy. 


332        SYMPTOMS. LATENT  PHTHISIS,    ISTKIND.     [Part  II, 

381.  Our  reflections  on  the  previous  observations  are 
equally  applicable  to  this  last.  When  we  first  saw  the  pa- 
tient the  cough  had  only  been  present  two  months,  and  al- 
ready large  excavations  existed  in  the  left  lung.  It  had, 
therefore,  been  preceded  by  tubercles,  which  cannot,  at  least 
in  this  instance,  be  considered  a  result  of  bronchitis.  The 
condition  of  the  gastric  naucous  membrane  indicated  a  recent 
alteration  ;  the  intestinal  ulcerations  were  dependant  upon, 
and  consecutive  to  phthisis.  It  is  then  to  the  lungs  alone 
that  we  can  attribute  the  intense  febrile  phenomena  experi- 
enced by  the  patient  during  the  first  six  months  of  her  pro- 
tracted illness  ;  for  no  one,  doubtless,  will  believe  the  fever  to 
have  been  a  simple  ague,  which  does  not  diminish  the  strength 
and  appetite,  so  as  to  force  the  patient  to  remain  in  bed. 

Some,  however,  may  still  consider  our  conclusions  precipi- 
tate; but  let  them  remember  that  this  patient  was  very  intelli- 
gent, her  memory  good,  that  she  was  questioned  with  the 
greatest  care,  that  all  the  organs  were  carefully  examined 
after  death  ;  and  they  will  1  think  admit,  that  if  the  facts  are 
rigorously  correct,  our  conclusions  are  legitimate.  While  we 
ought  always  to  avoid  deducing  consequences  from  doubtful 
facts,  let  no  such  hesitation  exist  about  those  which  are  well 
ascertained,  especially  when  no  complications  are  present  to 
render  their  interpretation  difficult. 

382.  We  have  said  that  the  redness,  combined  with  slight 
softening  of  the  membrane  lining  the  anterior  surface  of  the 
stomach,  was  a  recent  alteration }  and  our  opinion  is  confirmed 
by  the  inconsiderable  epigastric  pains  and  nausea  which  came 
on  after  the  entrance  of  the  patient  into  the  hospital  ;  so  that 
in  this  instance,  as  in  the  first  two  observations  of  this  chapter, 
the  previous  anorexia,  experienced  by  the  patient  some  time 
before  death,  was  not  dependant  on  any  appreciable  alteration 


Chap.  8.]  2d  ;  impossible  to  recognise  it  early.     333 

of  the  mucous  membrane,  but  on  the  general  phenomena, 
perhaps  the  febrile  affection,  by  which  the  stomach  is  influ- 
enced in  common  with  other  organs. 

Relatively  to  the  distribution  of  the  pulmonary  artery,  we 
refer  the  reader  to  what  we  have  said  in  the  first  part  of  this 
work  (11),  and  shall  merely  observe,  that  the  left  lung  was 
almost  wholly  converted  into  excavations,  and  the  grey  and 
opaque,  or  semi-transparent  substance  ;  that  on  the  right  side 
there  were  barely  two  fifths  of  the  lung  permeable  to  the  air, 
and  that  the  respiratory  function  was  almost  entirely  confined 
to  this  diminished  surface. 

383.  The  following  observation  is  another  example  of  latent 
phthisis,  the  progress  of  which  was  so  chronic  and  obscure 
that  it  was  not  recognised  durino;  life. 


THIRTIETH     OBSERVATION. 

A  WOMAN,  set.  31,  of  a  delicate  constitution,  great  sensibility, 
and  subject  to  shortness  of  breath  from  her  infancy,  complained 
of  being  liable  to  frequent  indispositions  for  several  years  past. 
She  said  she  was  not  subject  to  cold  ;  but,  in  referring  to  the  first 
symptoms  of  deranged  health,  we  discovered  that  for  seven  years 
she  had  expectorated  a  little  every  morning,  and  that  during 
the  first  eighteen  months  of  this  period  she  had  had  a  constant 
cough.  This  was  never  inconvenient,  and  ceased  spontane- 
ously after  a  long  voyage  and  a  residence  of  three  months  on 
the  sea  side,  although  her  habits  of  life  were  not  different  from 
what  they  had  been  previously.  She  did  not  recollect  to  have 
since  taken  cold,  but  the  cough  was  excited  momentarily  by  fog- 
gy weather  and  strong  scents.     During  the  last  three  years  her 


334  SYMPTOMS. LATENT  PHTHISIS,    2d  KIND;     [Part  II, 

usual  dyspnœa  had  ratlier  increased.  At  the  commencement 
of  this  period  her  digestion  became  languid,  and  now  and  then 
she  suffered  from  a  sense  of  weight  and  prickings  in  the  right 
hypochondrium  ;  the  skin  assumed  a  yellowish  tint,  and  an  or- 
ganic affection  of  the  liver  was  supposed  to  exist;  for  four  or 
five  months  she  was  treated  by  calomel  and  purgatives  ;  her  diet 
was  much  restricted,  although  her  appetite  was  but  slightly  di- 
minished. This  treatment  did  not  relieve  her.  Afterwards  the 
digestive  functions  became  more  deranged  ;  the  appetite  de- 
creased, and  the  catamenia  were  suspended  at  diflerent  intervals 
for  three  or  four  months,  and  had  been  wholly  suppressed  for 
the  seven  months  preceding  her  admission  into  La  Charité, 
January  2d,  J  823.  She  had  been  subject  to  sore  throats  and 
palpitations  ;  the  thirst  was  occasionally  urgent  the  last  three 
years  ;  she  had  never  had  hcemoptysis. 

January  2d.  Yellowish  tinge  over  the  whole  surface  ;  con- 
junctivas, natural  ;  brownish  spots  on  face  ;  considerable  de- 
bility ;  lassitude  in  the  limbs  ;  prickings  in  the  legs,  back,  and 
sides  of  the  chest  ;  speech,  rather  hurried;  no  dyspnœa  when 
quiet,  but  it  is  brought  on  by  the  least  exertion  ;  no  cough  nor 
expectoration  ;  percussion,  every  where  clear  ;  respiratory  mur- 
mur, natural,  except  under  the  right  shoulder-blade,  where  it 
was  stronger  than  in  the  corresponding  point  on  the  left  side. 
Pulse,  rather  quick  ;  heat  moderate  ;  tongue,  clean,  moist,  of 
a  pale  pink  color  ;  appetite,  diminished  ;  no  thirst  ;  digestion, 
easy,  especially  of  animal  food  ;  epigastrium,  resisting,  as  from 
some  flat  surface  underneath;  hypochondria,  yielding;  stools, 
rare  ;  urine  copious  and  without  pain.  The  patient  complain- 
ed only  of  weakness  and  pain  at  the  back  of  the  neck. 

(Infusion  of  sapon.  offic.  for  drink  ;  extract  of  gentian  3j., 
twice  a  day  ;  quarter  of  the  house  allowance). 

She  remained  nine  months  in  the  hospital,  where  she  died  on 


Chap.  8.]     IMPOSSIBLE    TO    RECOGNISE    IT    EARLY.  335 

the  2Sth  of  September.  During  this  period  we  examined  her 
every  ten  days,  more  frequently  during  the  last  month,  and  the 
following  was  the  result  :  —  At  the  end  of  February  there  was 
a  slight  cough,  although  then  and  until  September  the  patient 
assured  us  that  she  did  not  cough  ;  the  breathing  was  quick- 
ened by  the  slightest  movement,  but  from  the  absence  of 
cough  leading  us  to  suppose  this  to  be  owing  to  general  weak- 
ness, we  paid  but  little  attention  to  it.  During  the  last  fif- 
teen days  of  September  the  cough  became  much  more  f-equent, 
and  u>e  then  heard  it  for  the  first  time.  On  the  2-^d,  there 
were  some  nummulated  sputa,  which  made  us  suspect  phthisis, 
but  auscultation,  imperfectly  employed  the  same  day,  gave  no 
satisfactory  information.  The  pulse  v^^as  always  small  and 
weak,  and  was  but  slightly  accelerated  until  after  the  first  six 
months.  In  general  there  was  slight  increase  of  heat  in  the 
evening,  and  during  the  last  month  only,  occasional  rigors  with 
night  perspirations,  occupying  the  neck  and  chest.  The  ap- 
petite was  variable  ;  during  the  first  seven  months  she  ate  a 
fourth  or  an  eighth  of  the  house  allowance  ;  after  this  there 
was  complete  anorexia.  Digestion  was  almost  always  dif- 
ficult, but  rather  less  so  during  part  of  the  fourth  and  fifth 
months,  when  boluses  of  ox-gall  were  prescribed  ;  there 
was  some  nausea  during  the  last  forty  days.  At  the  com- 
mencement and  during  the  course  of  this  last  period,  she 
complained  of  pains  in  the  neck  and  of  difficult  deglutition, 
particularly  just  when  the  food  was  entering  the  stomach. 
The  thirst  was  always  rather  urgent  in  the  evening. 

From  the  fifth  month  the  liver  descended  below  the  ribs, 
and  she  was  sensible  to  the  presence  of  a  weight  falling  to  the 
right  or  left  as  she  changed  her  position  in  bed. 

The  tongue  was  constantly  the  seat  of  heat  and  unpleasant 
pricking  sensations,  and  retained  its  natural  color  until  the  end  of 


336        SYMPTOMS. LATENT  PHTHISIS,    2d    KIND  J    [Part  11, 

August.  It  was  afterwards  covered  with  white,  rounded,  vari- 
ably thick  patches,  which  lasted  one  or  two  days,  re-appeared 
after  irregular  intervals.  At  first  no  change  took  place  in  the 
color  of  the  tongue  ;  it  subsequently  becan-je  red.  A  similar 
exudation  took  place  on  the  roof  of  the  mouth  and  inner  sur- 
face of  the  cheeks  and  lips. 

Colic  pains  were  frequent,  sometimes  very  acute,  and  dur- 
ing the  last  six  months  there  was  occasional  diarrhœa. 

The  yellow  state  of  the  skin  persisted,  and  towards  the 
middle  of  July  the  brown  spots  on  the  face,  which  were 
light-colored  and  small  when  we  first  observed  the  patient, 
became  darker,  and  gradually  extended  over  the  whole  face, 
like  a  mask.  Œdema  of  the  lower  part  of  the  legs,  during 
the  last  six  months.  The  debility  progressed  slowly,  and  the 
patient  was  confined  to  her  bed  the  last  fifteen  days  only. 

Opening  of  the  corpse  thirty-four  hours  after  death. 

Exterior.  —  Extreme  emaciation  ;  slight  œdema  of  the 
lower  part  of  the  legs. 

Head.  —  Some  arachnoidean  granulations  in  the  course  of 
the  longitudinal  sinus  ;  the  brain  was  yellowish  on  the  surface, 
of  firm  consistence  ;  the  remainder  of  the  encephalon  was 
healthy. 

Neck.  —  Base  of  the  tongue,  rather  red,  and  covered  with 
a  false  pultaceous  membrane  ;  larynx  and  epiglottis,  natural  ; 
the  trachea  was  filled  by  a  white  frothy  fluid  ;  its  mucous 
membrane  was  healthy. 

Thorax.  —  Left  lung,  free  ;  slight  adhesions  of  the  right 
upper  lobe,  corresponding  to  a  large  tuberculous  excavation, 
lined  by  a  thin  false  membrane,  almost  wholly  in  contact  with 
healthy  lung.  Numerous  small  excavations  communicated 
with  it,  which  were  surrounded  by  slightly  infiltrated  or  indu- 


Chap.  8.]    IMPOSSIBLE    TO    RECOGNISE    IT    EARLY.  337 

rated  pulmonary  tissue  ;  the  two  lower  thirds  of  this  lung 
were  engorged,  and  of  a  pale  red  color,  in  the  left  lung  the 
engorgement  was  less  considerable,  but  at  the  summit  there 
were  numerous  small  excavations,  containing  the  remnants  of 
tuberculous  matter.  On  both  sides,  the  bronchia  communi- 
cating with  the  excavations,  were  of  an  extremely  pale  pink 
color,  and  very  thin  ;  elsewhere,  they  were  pale  ;  in  all,  the 
mucous  membrane  was  of  normal  consistence  and  thickness. 
There  were  about  six  ounces  of  serous  fluid  in  the  left,  pleura. 
Heart,  of  moderate  volume  ;  lining  membrane  of  left  ven- 
tricle and  aorta  of  a  bright  red  ;  this  color  extended  to  the 
middle  arterial  tunic,  which  was  not  otherwise  affected. 

Abdomen.  —  The  mucous  membrane  of  the  œsophagus  was 
pale,  and  everywhere  covered  by  a  soft  pultaceous  membrane, 
which  seemed  simply  in  contact  with  it.  The  stomach  was 
small  ;  its  lining  membrane  and  that  of  the  small  intestine  were 
everywhere  normal,  as  regards  color,  consistence,  and  thick- 
ness ;  that  of  the  colon  was  greyish,  and  soft  as  mucus  in  its 
two  lower  thirds  ;  mesenteric  glands  natural.  The  liver, 
though  not  increased  in  volume,  descended  below  the  ribs  an 
inch  and  a  half;  it  was  of  a  deep  yellow  color,  like  gamboge, 
fatty,  and  of  moderate  consistence.  The  bile  of  gall  bladder 
was  of  a  dirty  reddish  color,  and  thick  ;  the  kidneys  were 
pale  and  a  little  enlarged  ;  the  other  viscera  of  the  abdomen 
were  healthy. 

384.  The  latent  character  of  the  disease  is  here  so  evi- 
dent, that  long  reflections  on  our  part  would  be  wholly  super- 
fluous. During  the  nine  months  that  the  patient  remained  in 
the  hospital,  she  may  almost  be  said,  with  the  exception  of 
the  last  fifteen  days,  to  have  had  no  cough  ;  and  surely  no  one 
T   2 


338  SYMPTOMS. LATENT  PHTHISIS.    2d  KIND  ;    [Part  II, 

can  doubt  that  the  excavations  in  the  lungs  existed  anteriorly 
to  this  period.  The  only  difficulty  we  can  have,  is  to  know 
when  the  disease  originated.  If,  on  inspection  after  death, 
the  lungs  had  been  the  only  organs  profoundly  affected,  we 
might  refer  the  origin  of  phthisis  to  the  period  at  which  the 
derangement  in  the  patient's  health  commenced  ;  but  the 
liver  was  diseased,  and  probably  had  been  so  for  some  time, 
and  as  it  had  been  supposed  by  some  for  a  long  time  to  be 
the  sole  organ  affected,  one  might  attribute  to  it  the  greater 
number  of  the  general  symptoms  which  were  present  sev- 
eral years  before  death.  If,  however,  we  reflect  that  three 
years  anterior  to  any  alteration  in  the  color  of  the  skin,  the 
patient  was  attacked  with  a  chronic  pulmonary  catarrh,  not 
intense  certainly,  but  constant  during  eighteen  months,  that 
after  its  disappearance  the  cough  was  easily  renewed  by  the 
slightest  cause,  such  as  odors,  fogs,  &,c.  ;  that  the  alteration 
of  the  liver  is  one  almost  peculiar  to  (161),  and  depending  on 
phthisis,  and,  consequently,  subsequent  to  the  existence  of  the 
latter;  we  shall  be  induced  to  believe  that  the  presence  of 
tubercles  in  the  lungs  must  be  referred  to  the  period  of  the 
chronic  bronchitis  ;  and  to  their  influence  must  be  ascribed 
the  uneasiness,  and  other  symptoms  experienced  by  the  pa- 
tient from  this  moment  until  death.  It  would,  indeed,  be  im- 
possible to  have  any  correct  idea  of  the  very  gradual  progress 
of  the  debility,  and  the  general  mildness  of  the  symptoms,  if 
the  cause  to  which  we  refer  them  had  not  acted  very  slowly, 
and  the  tubercular  development  had  not  been  extremely 
chronic. 

385.  We  have  taken  for  granted  that  the  change  in  the 
color  of  the  skin  depended  upon  the  liver  ;  but  the  condition 
of  the  conjunctiva)  may  render  this  doubtful  ;  and  our  doubts 
may  be  strengthened  by  the  Aict,   tliat  in   no  instance  of  the 


Chap.  8.]  CICATRIZATION    OF    CAVITIES.  339 

fatty  degeneration  of  the  liver,  have  we  observed  an  analogous 
modification  of  the  color  of  the  skin.  We  must,  however,  re- 
member, that  the  patient  had  experienced  pricking  and  a 
sense  of  weight  in  the  right  hypochondrium,  symptoms  which 
were  not  present  in  the  cases  where  the  same  morbid  lesion 
was  observed. 

The  œsophagus  was  lined  by  a  false  membrane,  similar  to 
that  we  have  remarked  on  the  tongue  and  inside  of  the 
mouth  ;  during  a  month  the  oesophageal  deglutition  was 
more  or  less  difficult,  and  there  had  been  j)ains  in  the  neck. 
Now,  since  the  trachea  was  healthy,  we  are  inclined  to  refer 
both  symptoms  to  an  inflammation  of  the  lining  membrane  of 
the  oesophagus,  which  produced  the  exudation  just  spoken  of. 
This  opinion  appears  highly  probable,  although  we  have  fre- 
quently observed  a  similar  exudation  to  the  one  in  question, 
without  these  accompanying  symptoms. 

386.  Let  us  also  remark  that,  notwithstanding  the  frequent 
variations,  the  diminutions,  and  finally  the  total  loss  of  appe- 
tite, the  gastric  mucous  membrane  was  perfectly  healthy. 

The  structure  of  the  excavations  also  merits  our  attention. 
The  largest  was  invested  by  a  false  membrane,  lying  upon 
almost  healthy  pulmonary  tissue  ;  this  fact  is  rare,  and  it  is 
only  in  analogous  instances,  when  the  number  of  tubercles  is 
small,  that  we  can  conceive  the  cure  of  phthisis  to  take  place, 
by  the  union  of  the  sides  of  the  cavity.  Lastly,  with  the  ex- 
ception of  a  pale  pink  tinge  near  the  cavities,  the  communica- 
ting bronchia  were  healthy,  which  fact,  as  well  as  the  history 
of  the  symptoms,  is  contrary  to  the  idea  of  chronic  bronchitis 
being  the  cause  of  tubercles. 


340         SYMPTOMS. LATENT  PHTHISIS,    2d  KIND  ;     [Part  II, 


THIRTY-FIRST     OBSERVATION. 

387.  A  YOUNG  woman,  set.- 21,  of  delicate  health  and  great 
sensibility,  had  quitted,  two  months  previously,  the  haber- 
dashery business,  to  enter  a  religious  establishment.  She  was 
well  formed,  with  moderate  embonpoint,  and  said  she  had 
been  ill  six  weeks  before  entering  the  hospital  of  La  Charité, 
September  24th,  1822  ;  she  attributed  her  illness  to  the 
coarse  nature  of  her  food.  The  menstrual  discharge  com- 
menced at  the  age  of  fifteen,  returned  every  fifteen  days  dur- 
ing the  first  three  years,  after  which  it  was  less  frequent,  but 
always  irregular,  and  accompanied  with  severe  pains,  princi- 
pally in  the  loins.  From  the  first  there  was  some  leucorrhœa, 
and  frequently  epigastric  pains  ;  these  had  much  increased  the 
last  six  weeks,  so  that  she  could  not  support  any  thing  upon 
the  abdomen,  and  they  were  exasperated  by  coarse  vegeta- 
bles, as  beans  ;  they  became  very  acute  at  night,  but  were 
moderated  during  an  hour  by  a  cordial  mixture,  which  pro- 
duced a  burning  sensation  in  the  epigastrium.  To  these 
symptoms  nausea  was  soon  added  ;  there  was  almost  complete 
loss  of  appetite,  with  frequent  colics,  occasional  diarrhoea, 
and  during  three  weeks,  daily  rigors,  followed  by  heat  and 
perspiration  ;  there  had  been  no  cough,  and  no  sensible  in- 
crease of  her  dyspnœa,  which  she  had  had  from  childhood. 

September  25th.  Face,  pale  ;  muscular  system,  firm  ;  slight 
loss  of  flesh  ;  sleep,  interrupted  ;  she  seldom  complained  of 
headache  ;  great  debility  ;  breathing,  rather  oppressed,  which 
is  referred  to  the  epigastrium  ;  no  cough  nor  expectoration  ; 
pulse,  very  slightly  accelerated  ;  heat,  natural  ;  tongue,  rather 


Chap.  8.]   IMPOSSIBLE  TO  RECOGNISE  IT  EARLY.      341 

moist,  whitish  ;  bad  taste  in  the  mouth,  which  is  clammy  ;  loss 
of  appetite  ;  no  thirst;  complains  of  pain  below  the  xyphoid 
cartilage,  without  any  increased  local  heat  ;  another  pain  is 
felt  around  the  umbilicus,  with  slight  increased  volume  of  the 
abdomen  ;  bowels,  constipated  for  some  days. 

(Solution  of  oxymel  for  drink  ;  emoUient  enema  ;  two  half 
rice  creams). 

The  patient  not  liking  the  oxymel,  an  infusion  of  succory 
was  substituted  ;  this  was  equally  disagreeable,  and  weak  tea 
with  milk  was  preferred. 

October  4th.  Some  slight  pains  in  the  throat  ;  respiration, 
laborious,  at  times  panting,  very  variable.  In  the  upper  part 
of  the  right  lung,  posteriorly,  there  was  indistinct  pectoriloquy; 
this  was  also  sometimes  heard  opposite  the  inferior  angle  of 
the  scapula  ;  the  voice  seemed  to  come  in  jerks  ;  in  other 
respects  the  respiration  seemed  natural  ;  there  was  no  cough, 
or  pain  in  the  chest  ;  there  were  some  heat  and  frequency  of 
the  pulse  in  the  evening,  with  persistence  of  the  epigastric 
pain.  9th.  Slight  cough  ;  tracheal  respiration  and  distinct 
pectoriloquy  between  the  scapulae,  more  extensively  heard  at 
the  right  than  the  left  side.  We  were  very  particular  in  our 
inquiries  as  to  the  state  of  the  respiration,  previous  to  the  pa- 
tient's entering  the  hospital  ;  and  the  only  answer  she  return- 
ed was,  that  she  was  attacked  with  a  cold  every  winter,  lasting 
from  one  to  two  months,  and  that  she  had  not  coughed  once 
for  the  last  twelve  months. 

Until  tlie  17th  of  November,  when  death  took  place,  no 
evident  change  occurred  in  the  state  of  the  chest  ;  the  sputa 
were  scanty,  sometimes  frothy  and  mucous,  at  others,  com- 
pletely opaque  and  flocculent  ;  the  cough  was  usually  trouble- 
some at  night,  and  accompanied  by  occasional  paroxysms  of 
dyspnoea.     During  the  last  three   weeks  the  pulse  became 


342  SYMPTOMS.  LATENT  PHTHISIS,    2d  KIND  ;    [Part  II, 

more  frequent,  with  increased  heat  in  the  evening  ;  no  perspi- 
rations or  rigors. 

The  epigastric  pains  were  only  momentarily  mitigated  by 
a  warm  bath  ;  they  afterwards  became  very  acute,  and  were 
usually  accompanied  by  increased  local  temperature  ;  they 
ceased  two  days  before  death.  From  the  20th  of  October 
she  was  attacked  with  bilious  vomitings,  recurring  several 
times  during  the  day,  and  increasing  in  frequency  to  the  last. 
The  patient  could  not  bear  the  same  drink  more  than  three 
days  in  succession,  and  at  length  became  disgusted  with  every 
thing.  The  tongue,  towards  the  close,  became  dry  ;  there 
were  occasional  colics  and  diarrhœa.  Great  agitation  during 
the  last  night,  but  no  delirium  or  loss  of  consciousness. 

Opening  of  the  corpse  twenty-seven  hours  after  death. 

Exterior.  —  Considerable  emaciation  ;  the  right  cheek, 
on  which  the  patient  lay  during  life,  was  of  a  livid  color. 

Head.  —  Slight  sub-arachnoidean  infiltration  ;  the  brain, 
and  parts  connected  with  it,  perfectly  healthy. 

Chest.  —  Some  clear  serous  fluid  in  the  pleurae;  lungs, 
free,  soft,  crepitating,  healthy  at  their  base,  indurated  at  their 
summit,  where  we  found  a  great  number  of  encysted  tubercles. 
Some  were  excavated  or  only  softened  ;  the  majority  were  still 
crude  ;  the  cysts  were  easily  separated  from  the  pulmonary 
tissue,  and  in  their  intervals  or  lower  down  there  were  numer- 
ous grey  granulations,  yellowish  at  their  centres.  The  bron- 
chia were  thin  and  of  a  deep  red.  The  heart  was  small  and 
of  a  bright  red  color. 

Abdomen.  —  Some  reddish  colored  serum  in  the  lumbar 
regions  ;  about  five  ounces  of  healthy  looking  pus  in  the 
pelvis.  The  omentum  was  closely  adherent  to  the  small  in- 
testine, as  were  also  some  of  the  convolutions  among  them- 


Chap.  8.]  ENCYSTED  tu:bercles.  343 

selves,  in  points  corresponding  to  ulcerations.  Numerous 
miliary  granulations  on  the  peritoneal  surface  of  the  small  in- 
testine, most  of  which  were  semi-transparent  ;  some  were 
slightly  opaque  in  the  centre,  and  all  were  situated  on  the 
adherent  surface  of  the  peritoneum.  The  mucous  membrane 
of  the  stomach  was  red  in  the  great  cul-de-sac,  over  an  extent 
of  two  inches  ;  healthy  in  the  vicinity  of  the  pylorus  and  ante- 
riorly ;  soft  as  mucus  in  the  remainder  of  its  extent.  There 
were  numerous  ulcerations  throughout  the  whole  of  the  small 
intestine,  situated  transversely,  and  with  intervals  of  from  two 
to  six  inches  ;  many  of  them  encircled  the  gut.  The  inter- 
vening membrane  was  healthy  ;  in  the  ulcerated  points  it  was 
destroyed,  and  the  submucous  layer  was  thin  and  of  a  greyish 
color  ;  and  in  some  points  the  muscular  tunic  was  exposed, 
thickened,  and  its  fibres  sometimes  separated  by  tuberculous 
granulations.  The  transverse  and  right  lumbar  colon  present- 
ed two  radiated  ulcerations  of  the  size  of  a  dollar  or  larger,  and 
similar  in  their  structure  to  those  of  the  small  intestine  ;  be- 
tween these  there  was  a  much  smaller  ulceration,  lined  by  the 
peritoneum.  The  mucous  membrane  was  pale  and  much  soft- 
ened in  the  transverse  colon.  Mesenteric  glands,  more  or 
less  tuberculous,  and  the  portion  of  the  gland  not  yet  trans- 
formed was  of  a  somewhat  bright  red  color.  The  liver  was 
voluminous,  pale,  yellow,  spotted  with  red,  easily  torn,  and 
adipous  ;  the  gall-bladder,  rather  small,  and  contained  bile  of 
the  color  and  consistence  of  treacle  ;  the  other  viscera  of  the 
abdomen  were  healthy. 

388.  The  fact  of  pectoriloquy  having  been  observed  before 
the  cough  is  an  evident  proof  of  the  latent  nature  of  the  dis- 
ease. But  to  what  period  ought  we  to  refer  the  origin  of  the 
tubercles  ?    The  solution  of  this  question  appears  to  us  impos- 


344         SYMPTOMS. LATENT  PHTHISIS,    2d  KIND  ;    [Part  II, 

sible.  For  if  we  go  back  to  a  period  anterior  to  the  six  weeks 
preceding  the  entrance  of  the  patient  into  the  hospital,  that  is, 
farther  back  than  the  period  considered  by  herself  as  the 
commencement  of  her  illness,  we  cannot  lay  greater  stress 
upon  the  last  cold  than  upon  the  one  preceding,  for,  during 
the  interval  her  health  was  good.  However,  the  size,  num- 
ber and  structure  of  the  ulcerations  of  the  small  intestine 
seemed  to  indicate  that  the  pulmonary  tubercles,  on  which 
they  depended,  existed  anteriorly  to  the  apparent  origin  of  the 
disease. 

389.  At  the  time  we  collected  this  observation  we  had  not 
specially  directed  our  attention  to  the  softening  with  diminish- 
ed consistence  of  the  gastric  mucous  membrane,  and  we  have 
only  here  noted  its  extreme  softening.  It  is,  however,  proba- 
ble that  both  alterations  existed,  the  patient  having  presented 
in  an  intense  degree,  and  during  a  considerable  space  of  time, 
the  symptoms  which  characterize  this  double  lesion,  viz.,  ano- 
rexia, epigastric  pains,  nausea,  disgust  for  every  kind  of  drink, 
and  lastly  bilious  vomitings. 

The  purulent  effusion  in  the  pelvis,  was  the  result  of  an 
acute  and  recent  peritonitis,  occurring  doubtless  during  the  last 
twenty-four  hours  ;  at  least  we  are  inclined  to  this  conclusion, 
because  when  we  last  saw  the  patient  no  symptoms  of  perito- 
nitis existed,  and  during  the  night  on  which  she  died  she  ex- 
perienced unusual  agitation  without  any  cerebral  derange- 
ment ;  also,  because  at  the  close  of  other  chronic  diseases 
we  have  remarked  the  same  agitation,  occurring  at  the  same 
period,  and  only  under  similar  circumstances.  We,  however, 
regard  this  mode  of  viewing  the  subject  as  conjecture  merely, 
and  have  only  employed  it  to  show  that  diseases,  when  near 
their  termination,  are  not  without  interest  for  the  observer. 


Chap.  8.]  ENCYSTED    TUBERCLES.  345 


THIRTY-SECOND    OBSERVATION. 

390.  A  COOK,  aet.  24,  of  a  weak  and  delicate  constitution, 
middle  stature,  and  having  been  much  subject  to  leucorrhœa 
both  before  and  subsequently  to  the  first  appearance  of  the  cat- 
amenial  discharge,  had  been  ill  six  weeks  when  she  was  admit- 
ted to  the  hospital  of  La  Charité.  At  the  commencement, 
she  had  experienced  colics,  and  pains  of  a  very  indeterminate 
nature;  these  pains,  which  were  acute  and  unaccompanied  by 
fever  during  the  first  weeks,  afterwards  diminished  ;  fever 
then  succeeded,  and  she  was  frequently  liable  in  the  evening 
to  rigors,  followed  by  heat  and  perspiration.  From  the  first 
the  appetite  was  diminished,  and  soon  ceased  altogether,  the 
patient  only  taking  a  small  quantity  of  food  in  the  morning, 
having  remarked  that  in  the  evening  it  was  always  the  cause 
of  increased  abdominal  pain.  Some  purgative  medicine,  dur- 
ing the  first  fifteen  days,  produced  slight  diarihœa  ;  there 
were  scarcely  any  increase  of  thirst,  and  no  cough.  The  cat- 
amenia  had  returned  at  their  usual  period  on  the  16th  of  the 
last  month. 

On  the  15th  of  July,  1824,  the  day  after  her  admission,  the 
face  was  pale  ;  there  was  slight  general  debility  ;  percussion  of 
chest,  clear  ;  respiration,  every  where  natural  ;  no  cough  or 
expectoration;  she  had  however  experienced  nineteen  months 
previously,  after  a  protracted  cold,  an  hsemoptysis,  wliich  con- 
tinued more  or  less  during  six  weeks  ;  the  cold  returned  in 
the  following  winter  ;  in  the  interval  and  ever  since  there  had 
been  some  difficulty  of  breathing,  but  no  cough.  The  skin 
was  a  httle  hot,  and  the  pulse  very  slightly  accelerated  ;  the 
u  2 


346         SYMPTOMS. LATENT  PHTHISIS,    2d  KIND  ;    [Part  11^ 

patient  had  had  some  rigors  the  previous  evening.  The  tongue 
was  large,  rather  moist,  of  a  whitish  brown  coU)r  ;  the  mouth, 
clammy  with  bitter  taste  ;  no  thirst  ;  warm  drinks  excited  dis- 
gust ;  cold  drinks  produced  coHc  ;  abdomen,  rather  tense  and 
sensible  to  pressure  throughout  ;  epigastrium,  painful  ;  suffer- 
ings increased  by  all  movements  and  during  the  febrile  exa- 
cerbation in  the  evening  ;  occasional  colics  ;  two  stools,  daily. 

(Solution  of  gum  syrup  ;  emollient  enema  ;  emollient  fomen- 
tations ;  hipbath;  two  soups). 

From  this  moment  up  to  the  26th  of  August,  the  day  of 
her  death,  there  was  no  cough,  with  the  exception  of  the  last 
ten  days  ;  she  then  attributed  it  to  throwing  off  the  bed 
clothes  during  the  night,  because  she  felt  too  warm  ;  it  ex- 
cited little  attention,  and  on  account  of  her  weak  state,  auscul- 
tation was  not  practised.  There  was  always  more  or  less  heat 
in  the  evening,  sometimes  preceded  by  rigors,  and  constantly 
followed  by  perspiration.  Towards  the  end,  the  pulse  became 
very  rapid,  small  and  weak. 

July  17th.  The  patient  vomited  some  mouthfuls  of  bile  ; 
this  was  soon  repeated  with  increased  frequency  and  copious- 
ness; it  occurred  almost  daily  until  death,  amounting  sometimes 
to  several  pints  of  a  greenish,  yellow-colored  bile.  The  epigas- 
tric pains  were  very  violent,  accompanied  with  heat,  and  were 
always  increased  shortly  before  vomiting  ;  from  the  middle  of 
August  they  were  only  sensible  at  that  period.  The  abdo- 
men increased  in  volume,  was  often  hot  and  painful  ;  the  diar- 
rhœa  was  moderate  and  remittent  ;  the  appetite,  which  was 
usually  depressed  or  absent,  occasionally  revived,  when  the 
patient  relished  a  little  soup  and  a  fresh  egg,  without  after- 
wards vomiting.     The  debility  rapidly  increased. 

On  the  26th  of  August,  during  the  visit,  the  patient  was 
sensible  of  her  approaching  dissolution,  and  pointed  out  to  us 


Chap.  8.]  ENCYSTED    TUBERCLES.  347 

some  lenticular  bluish  spots,   wiiich  had  just  appeared  on  the 
chest  and  hands.      She  expired  at  three,  p.  m.,  the  same  day. 

Opening  of  the  corpse  eighteen  hours  after  death. 

Exterior.  —  Extreme  emaciation  ;  flaccidity  of  the  limbs  ; 
persistence  of  the  lenticular  spots  observed  during  life  ;  no 
vibices. 

Head. — The  upper  half  of  the  brain,  firmer  than  the 
lower  ;  two  small  spoonsful  of  serous  fluid  in  the  lateral  ven- 
tricles.    The  tuber  annulare  and  cerebellum,  rather  soft. 

Neck.  —  Epiglottis,  larynx  and  trachea,  natural. 

Thorax.  —  Right  lung,  every  where  closely  adhering  to 
the  costal  pleura  ;  the  upper  lobe  contained  innumerable  mil- 
iary, grey,  semi-transparent  granulations,  more  or  less  opaque 
in  their  centre  ;  there  were  none  in  the  lower  lobe.  The 
left  lung  presented  loose  cellular  adhesions,  with  every  vi'here 
grey,  semi-transparent  granulations,  and  at  its  summit  a  mid- 
dle-sized tuberculous  excavation,  lined  by  a  semi-cartilaginous 
membrane,  applied  either  on  healthy  lung  or  granulations,  and 
covered  by  a  soft  albuminous  exudation.  The  bronchia  were 
healthy  ;  heart,  rather  small  ;  aorta,  natural. 

Abdomen.  —  The  viscera  and  abdominal  parietes  were 
lined  over  nearly  the  whole  extent  by  a  false  greyish  mem- 
brane, either  immediately  in  contact  with  itself,  or  with  a  dull 
white,  yellowish,  friable  substance,  arranged  in  patches, 
which  were  larger  and  more  numerous  in  the  small  pelvis 
than  any  where  else  ;  in  a  word,  tuberculous  matter  in- 
terposed between  its  layers.  This  was  most  abundant  in  the 
pelvis.  The  stomach,  of  moderate  volume,  contained  some 
bilious  fluid.  The  principal  portion  of  the  great  cul-de-sac 
was  of  a  pearl  white,  and  in  the  corresponding  point  the  mu- 
cous membrane  was  extremely  thin,  and  of  the  consistence  of 


348  SYMPTOMS.  LATENT  PHTHISIS,  2d  KIND  ;    [Part  II, 

mucus  ;  a  similar  alteration  existed  near  the  pylorus,  over  a 
surface  of  about  four  inches  ;  between  these  two  softened  por- 
tions there  were  bands  from  three  to  four  lines  wide  in  the 
same  state,  while  the  intervening  membrane  was  healthy. 
That  of  the  small  intestine  offered  some  inconsiderable  ulcer- 
ations, and  was  every  where  extremely  softened.  There 
were  two  ulcerations  of  three  lines  in  diameter,  with  a  much 
less  softened  state  of  the  lining  membrane  in  the  large  intes- 
tine ;  some  redness  in  the  rectum.  The  liver  was  rather  redder 
than  natural,  and  easily  broken  down.  The  bile  of  the  gall- 
bladder was  of  a  brown  color,  and  moderately  dense.  The 
interior  of  the  uterus  and  the  upper  half  of  its  neck  were  of  a 
dull  yellowish  white,  with  an  uneven  surface  ;  this  was  caused 
by  the  transformation  of  the  superficial  layer  into  very  firm 
tuberculous  matter,  of  about  a  line  in  thickness  ;  beneath  this 
were  numerous  miliary  granulations  of  the  same  nature  ;  the 
remaining  portion  of  the  parietes  was  free  from  alteration. 

391.  The  analogy  between  this  last  observation  and  the 
preceding  is  most  striking,  whatever  may  be  the  point  of  view 
from  which  we  judge  of  them.  Both  individuals  were  nearly 
of  the  same  age,  similar  constitutions,  and  equally  liable  to  pro- 
tracted bronchial  affections  and  gastric  symptoms  ;  very  little 
cough  existed  in  either  case  towards  the  termination  of  the  dis- 
ease, and  after  death  analogous  lesions  were  found  in  the 
lungs  and  mucous  membrane  of  the  stomach.  The  tubercu- 
lous affection  in  this  last  instance,  as  in  the  preceding  one, 
had  also  evidently  preceded  the  cough  ;  and  on  account  of  the 
haemoptysis  which  had  occurred  eighteen  months  before  the 
entrance  of  the  patient  into  the  hospital,  and  the  slight  dys- 
pnœa  which  had  existed  from  that  time,  we  may  consider  the 


Chap.  8.]  SUMMARY.  349 

tubercular  development    to    have    commenced    at  the   same 
period. 

The  state  of  the  uterus  and  of  the  peritoneal  cavity  is  not 
without  interest.  A  false  membrane  invested  the  anterior  abdo- 
minal parietes  and  viscera,  enclosing  between  its  layers  a  dull 
yellow  substance,  in  patches  of  various  dimensions.  This  might 
be  regarded  by  some  as  solidified  pus  ;  but  if  we  reflect  that  it 
presented  the  characters  of  tuberculous  matter,  —  that  we 
have  never  found  a  similar  deposition,  except  in  cases  of 
phthisis,  - —  that  its  occurrence  on  the  surface  of  a  false 
membrane  is  not  more  difficult  to  conceive  of  than  on  the 
lining  membrane  of  the  ureters,  vas  deferentia  or  vesiculae  sém- 
inales (Obs.  5.  6),  we  cannot,  I  think,  suppose  it  other  than 
tuberculous  matter.  With  regard  to  the  tuberculous  trans- 
formation of  the  inner  surface  of  the  uterus,  it  must  have  taken 
place  rather  rapidly,  since  no  derangement  of  the  uterine 
functions  existed  previous  to  the  patient's  admission  into  the 
hospital  (183). 

392.  The  tuberculous  matter  was  also  at  the  same  stage  of 
development  in  every  organ,  which  seems  to  point  out  the 
influence  of  a  general  cause  acting  upon  many  parts  at  the 
same  time,  and  favors  what  we  have  advanced  as  to  the  nature 
of  the  deposition  between  the  layers  of  the  false  membrane. 

393.  The  six  observations  we  have  just  detailed  are  not  the 
only  examples  we  have  collected  ;  two  of  those,  included  in 
another  division  of  our  work,  might  be  added  to  the  number. 
One  (Obs.  4)  refers  to  a  man  who  died  after  a  violent  diar- 
rhœa  of  five  months  duration,  having  coughed  only  during  the 
last  six  weeks,  and  in  whose  lungs  we  found  numerous  tuber- 
cles and  excavations,  with  very  extensive  intestinal  ulcerations. 
The  organic  alterations  were  such  that  it  was  impossible  not 


350  SYMPTOMS.  — LATENT  PHTHISIS  ;         [Part  II, 

to  suppose  that  tubercles  were  in  the  lungs  anterior  to  the 
couQ^h  ;  and  since  the  diarrhoea  was  probably  caused  by  the 
commencement  of  intestinal  ulcerations  (which  we  have  shown 
are  a  consequence  of  phthisis),  we  must  admit  the  origin  of 
the  pulmonary  tubercles  to  have  dated  from  the  same  period. 
The  other  instance  (Obs.  9)  was  that  of  a  girl,  aged  nineteen, 
who  had  been  ill  seven  months,  but  who  had  coughed  only  a 
few  weeks  before  entering  the  hospital  ;  pectoriloquy  was  then 
distinct  ;  the  sputa  were  isolated  and  flocculent,  which  facts, 
combined  with  other  reasons,  proved  the  existence  of  tuber- 
cles anterior  to  the  cough. 

394.  Out  of  one  hundred  and  twenty-three  cases  of 
phthisis,  eight  (or  one  fifteenth),  were  examples  of  pulmo- 
nary tubercles  which  were  latent,  or  in  other  words,  which 
preceded  the  cough,  during  a  period  varying  from  six  months 
to  two  years.  This  proportion,  although  considerable,  is  doubt- 
less much  less  than  it  really  is,  if  the  haemoptysis,  which  so 
often  precedes  the  cough  and  expectoration,  is  the  effect,  and 
not  a  precursory  symptom  of  tubercles-  In  fact,  haemoptysis 
had  appeared  before  the  other  symptoms  in  seven  of  the  cases 
cited  as  specimens  of  what  we  have  termed  "  regular  phthisis." 

The  eight  cases  of  latent  phthisis  may  be  naturally  divided 
into  two  classes  :  in  one,  the  tubercles  existed  a  more  or  less 
long  period  before  exciting  cough  or  expectoration,  or  even 
any  important  general  symptoms  (Obs.  4,  30,  31,  32)  ;  in 
the  other,  they  gave  rise  to  intense  general  symptoms,  as 
fever,  emaciation,  anorexia,  &ic.,  before  they  excited  cough 
or  expectoration  (Obs.  9,  27,  28,  29).  The  indistinctness  of 
the  symptoms  in  the  first  division  diverted  the  attention  from 
precisely  ascertaining  the  condition  of  the  lungs;  but  in  the 
other  instances,  from  the  impossibility  of  referring  the  symp- 
toms to  any  particular  organ,  and  the  known   frequency  of 


Chap.  8.]  SUMMARY.  351 

phthisis,  the  presence  of  tubercles  ought  to  have  been  sus- 
pected ;  we  should  have  examined  every  local  symptonti, 
such  as  pain  in  the  side  or  between  the  shoulders,  haemopty- 
sis, &.C.,  and  especially  should  we  have  endeavored  to  ascer- 
tain the  exact  state  of  the  pulmonary  organs  by  means  of 
auscultation  and  percussion.  Had  this  been  done,  it  is  indeed 
probable  that  phthisis  would  have  been  recognised  in  all  the 
cases  of  the  second  series  long  before  the  presence  of  cough 
and  expectoration.  We  are  then  strongly  called  upon  to  have 
recourse  to  these  means  in  analogous  cases,  and  in  general 
whenever  there  is  emaciation,  and  it  is  doubtful  what  the 
diagnosis  is. 

395.  The  fact  that  tubercles  may  exist  in  the  lungs  without 
at  once  giving  rise  to  those  peculiar  symptoms  which,  sooner 
or  later,  are  almost  invariably  observed,  must  not  be  considered 
extraordinary,  since  this  may  be  the  case  in  all  diseases,  in- 
flammations of  parenchymatous  organs,  of  serous  membranes, 
sometimes  even  in  those  whose  course  is  acute,  as  softening 
of  the  brain,  &c.  &£C.  But  what  really  is  remarkable,  was 
the  violence  of  the  general  symptoms,  the  functional  derange- 
ment of  organs  which  presented  no  appreciable  organic  alter- 
ation, while  the  only  viscus  really  affected  seemed  functionally 
healthy.  It  is,  in  fact,  in  the  examples  of  simple  and  latent 
phthisis  (Obs.  27,  28,  29),  that  the  febrile  symptoms  have 
been  most  prominent,  and  the  disorder  of  the  digestive  func- 
tions most  protracted.  This  fact  confirms  what  we  have  pre- 
viously stated  (252),  that  in  the  majority  of  instances  the 
fever  in  phthisical  cases  is  dependant  on  tubercles  in  the  lungs, 
and  not  on  the  consecutive  morbid  changes,  such  as  intestinal 
ulcerations,  &;c.,  Sic. 

396.  In  the  present  state  of  our  knowledge,  it  seems  im- 
possible to  determine,   or   even  to  offer  any  conjecture  on  the 


352  SYMPTOMS. — AccTE  PHTHISIS;  [Part  II, 

nature  of  the  causes  which  thus  mask  the  presence  of  pul- 
monary tubercles.  We  cannot  attribute  it  to  deficient  sensi- 
bility by  which  the  lungs  become  insensible  to  the  presence 
of  tubercles,  since  six  eighths  of  the  cases  were  females,  and 
in  one  half  of  these,  anteriorly  to  the  cough,  the  febrile  symp- 
toms were  very  intense,  and  a  general  reaction  marks  as 
much  susceptibility  in  the  system  as  the  development  of  local 
symptoms  does.  The  presence  of  complications  equally  fails 
of  offering  any  explanation,  for  in  the  majority  of  instances 
they  did  not  exist. 

We  shall  again  refer  to  these   facts,    when  considering  the 
causes  of  tubercles  in  the  lungs. 


ARTICLE     II. 


ACUTE   PHTHISIS. 


The  observations  which  we  have  as  yet  detailed  demon- 
strate the  extreme  variations  in  the  duration  of  phthisis.  We 
have  seen  it  go  through  all  its  stages  in  periods  varying  from 
three  months  to  tiventy  years  (Obs.  10,  24)  ;  in  the  following 
examples  its  progress  has  been  still  more  rapidly  fatal  than  in 
any  which  have  preceded. 


THIRTY-THIRD     OBSERVATION. 

397.  A  GIRL,  set.  18,  of  a  tolerably  strong  constitution, 
with  brown  hair,  firm,  muscular  system,  with  moderate  em- 
bonpoint,  entered   the  hospital  of  La  Charité,  April  29th, 


Chap,  8.]  RAPIDLY    FATAL.  353 

1822.  She  had  been  little  subject  to  cold,  usually  in  good 
health,  and  dated  her  present  illness  only  fifteen  days.  At 
the  commencement,  she  was  attacked  by  rigors  with  shiver- 
ings,  followed  by  heat  and  perspiration  ;  the  rigors  were  re- 
peatedly renewed  ;  the  heat  increased  and  the  thirst  became 
urgent  ;  there  were  occasional  nausea,  and  more  rarely  some 
mouthfuls  of  bile  rejected  ;  complete  loss  of  appetite  and  fre- 
quent constipation  ;  the  debility  had  progressed  with  the  other 
symptoms  ;  lastly,  on  the  tejiih  day  from  the  commencement 
there  were  slight  cough  and  expectoration  ;  the  catamenia, 
present  from  the  age  of  fifteen,  had  been  absent  the  last  three 
months  ;  the  patient  had  not  kept  her  bed. 

April  30th.  Expression,  animated  ;  dull  headache  ;  general 
lassitude  ;  respiration,  thoracic  and  accelerated  (forty-four)  ; 
cough,  frequent  ;  sputa,  semi-opaque,  rather  greenish,  mingled 
with  bubbles  of  air  ;  pains  in  the  middle  of  the  sternum  and 
under  the  left  clavicle  ;  sonorous  râle  on  both  sides  of  the 
chest;  pulse,  one  hundred  and  three,  neither  full  nor  hard  ; 
heat  intense  ;  night  sweats  ;  tongue,  red  on  the  edges,  whitish 
in  the  centre  ;  mouth,  dry,  clammy,  and  with  a  bitter  taste  ; 
thirst,  urgent  ;  anorexia  ;  one  liquid  stool  during  the  night. 

(Twelve  leeches  to  the  labia  ;  acidulated  infusion  of  vio- 
lets for  drink  ;  solution  of  gum  syrup  ;  two  emollient  ene- 
mata). 

May  1st.  Increased  uneasiness  ;  pain  in  the  right  side  of 
the  chest  ;  expectoration,  copious,  greenish,  a  little  striated 
with  yellow  lines  ;  auscultation  as  before. 

(A  poultice  to  the  painful  part). 

May  2d.  No  remarkable  change  ;  sweat  in  the  night  ;  some 
diarrhoea  and  sudamina. 

(Blister  to  the  chest). 

w  2 


354  srMPTOMS.  —  acute  phthisis  ;  [Part  II, 

From  this  period  to  the  19th  of  May,  the  day  of  her  death, 
the  progress  of  the  disease  was  rapid  and  regular  ;  the  respi- 
ration, thoracic,  frequent,  varying  from  forty-nine  to  even  sixty 
times  in  a  minute  ;  cough,  very  violent,  especially  during  the 
night  ;  the  expectoration  Avas  more  or  less  copious,  mucous, 
frothy,  or  wholly  opaque,  greenish,  without  air,  and  streaked 
with  yellow  hues  ;  percussion  of  the  chest,  frequently  repeated, 
was  clear  ;  over  the  right  side  there  was  much  mucous  râle  on 
7th.  On  the  10th,  the  respiratory  murmur  was  not  so  distinct 
on  this  side  as  on  the  left,  and  a  little  crepitation  was  heard 
about  the  mamma.  On  the  18th,  at  each  inspiration,  there  was 
a  kind  of  liquid  crackling  over  nearly  all  the  front  of  the  chest, 
with  a  httle  crepitation  on  the  left  side.  The  pulse  gradually 
quickened  on  the  16th,  (one  hundred  and  sixty-four)  ;  heat, 
much  elevated  and  dry;  constant  night  sweats  until  the  12th  ; 
anorexia  continued  ;  thirst,  very  urgent,  the  patient  drinking 
five  or  six  quarts  of  fluid  in  the  four  and  twenty  hours  ;  some 
nausea,  with  bilious  vomitings  and  epigastric  pains  the  last 
seven  days,  and  during  the  whole  time  there  was  slight  diar- 
rhoea. 

The  uneasiness  increased  ;  the  face  was  pale  and  express- 
ed surprise  ;  appearance,  much  fallen  on  the  16th.  During 
the  night  of  the  1 8th  there  was  slight  delirium,  with  embar- 
rassed utterance  ;  the  patient  cried  out  for  assistance  to  be 
relieved  of  the  sufferings  in  her  chest.  Death  took  place  at 
three,  a.  m.,  on  the  19th. 

The  blister  ceased  to  suppurate  some  days  before  death. 
She  continued  the  same  drinks  ;  emollient  enemata  were  fre- 
quently ordered  ;  and  during  the  last  week,  on  account  of  the 
dry  state  of  the  skin,  M.  Chomel  prescribed  some  warm 
baths. 


Chap.  8.]  RAPIDLY    FATAL.  355 

Opening  of  the  corpse  twenty-four  hours  after  death. 

Exterior.  —  Extreme    muscular   rigidity  ;    considerable 
emaciation. 

Head.  —  Slight  snb-arachnoidean  infiltration  ;  the  brain 
was  healthy. 

Thorax. — The  left  lung  offered  some  adhesions  posteri- 
orly ;  the  upper  lobe  contained  numerous  grey,  semi-trans- 
parent granulations,  and  small  tuberculous  masses  in  a  crude 
state,  surrounded  by  slightly  engorged  pulmonary  tissue  ;  the 
engorgement  was  more  considerable  in  the  base  of  the  lower 
lobe,  which  contained  few  granulations  ;  the  right  lung,  uni- 
versally adherent,  was  transformed  at  its  base  into  a  mass  of 
tuberculous  matter  of  a  pale  rose  tint,  to  the  extent  of  two 
inches  in  height  and  two  in  breadth,  occupying  nearly  the 
whole  circumference  of  this  part  of  the  lung  ;  it  was  perfo- 
rated by  a  kind  of  anfractuous  canal,  enclosing  a  small  quan- 
tity of  a  thick,  dark-colored  fluid.  Elsewhere  the  lung  pre- 
sented numerous  grey,  semi-transparent  granulations,  and 
small  softened  masses  of  tuberculous  matter  ;  its  tissue  was 
slightly  engorged. 

Abdomen.  —  The  gastric  mucous  membrane  was  covered 
by  a  viscid  mucus  nenr  the  pylorus,  and  had  some  irregular 
redness  in  the  great  cul-de-sac  ;  the  small  intestine,  colon, 
and  other  abdominal  viscera  were  healthy. 

398.  In  this  observation  the  interval  between  health  and 
disease  was  short  ;  the  cessation  of  one,  and  the  commence- 
ment of  the  other  were  well  marked  ;  the  duration  of  the  dis- 
ease was  thirty-five  days,  that  of  the  cough  twenty-five  only. 
The  violence  of  the  symptoms  is  as  remarka  le  as  the  rapid 
progress  of  the  affection.     At  first,  very  intense  febrile  move- 


356  SYMPTOMS.  —  ACUTE    PHTHISIS  ;  [Pait  II, 

ment,  associated  after  ten  days  with  cough,  expectoration  and 
dyspnœa  ;  the  latter  rapidly  increased  ;  on  the  sixth  day  of 
the  cough  the  breathing  was  forty-seven,  and  it  was  still  more 
accelerated  on  the  succeeding  days  ;  the  temperature  was 
much  elevated,  and  the  pulse  very  frequent  ;  all  pointed  out 
an  acute  affection  of  the  lungs.  The  percussion  of  the  chest, 
however,  was  clear,  the  results  of  auscultation  nearly  negative, 
not  favoring  the  idea  of  bronchitis,  and  only  giving  reason  to 
suspect,  towards  the  close  of  the  patient's  life,  the  first  degree 
of  pneumonia,  which  gave  no  explanation  of  the  preceding,  or 
even  the  actual  symptoms.  Under  these  circumstances,  was 
it  possible  to  recognise  the  nature  of  the  disease  ? 

399.  We  might  no  doubt  have  employed  auscultation  with 
greater  care,  and  have  studied  the  effects  of  the  voice  in  every 
part  of  the  chest;  but  supposing  this  to  have  been  done,  could 
we  have  formed  our  diagnosis  ?  We  think  not.  In  fact,  if  we 
had  detected  resonance  of  the  voice  in  the  lower  part  of  the 
right  side,  to  have  ascribed  it  to  an  excavation,  would  have 
been  to  have  formed  a  conclusion  in  opposition  to  the  general 
law*  of  the  developtnent  of  tuberculous  matter,  viz.,  from  the 
summit  to  the  base  of  the  lungs  ;  so  that  every  thing  seemed 
combined  to  falsify  diagnosis,  both  from  the  situation  of  the 
lesion  and  the  violence  of  the  symptoms. f 

The  absence  of  the  symptoms  of  pleurisy  or  pneumonia,, 
connected  with  the  appearance  of  the  sputa,  made  M.  Chomel 
for  a  moment  to  suspect  the  existence  of  phthisis  ;  but  so 
many  circumstances  were  opposed  to  the  idea,  that  he  ceased 

*  Out  of  one  hundred  and  twenty-three  cases,  this  is  the  only  example 
of  tuberculous  matter  developed  from  the  base  to  the  summit  of  the  lungs. 
—  Louis. 

t  Vide  note  on  page  326.  —  H.  1.  13. 


Chap.  8.]  DIFFICULT    OF    RECOGNITION.  357 

to  entertain  it.  The  fact,  however,  ought  not  to  be  forgotten  ; 
it  increases  the  value  of  the  expectoration  as  a  diagnostic 
sign,  and  shows  how  useful  it  is  to  observe  minutely  its  char- 
acters. 

400.  It  is  also  very  remarkable  that,  notwithstanding  the 
extreme  rapidity  of  the  tuberculous  development,  there  were 
scarcely  any  traces  of  inflammation  in  the  surrounding  tissues, 
more  particularly  in  the  right  lung. 

The  digestive  organs  were  too  incompletely  described  to 
allow  us  to  extend  our  remarks  on  the  gastric  symptoms. 
Nevertheless,  we  would  remark  that  the  vomiting  of  bile  con- 
nected with  the  dark  stripes  of  the  mucous  membrane  of  the 
stomach  might  lead  us  to  suspect  that  there  was  a  somewhat 
serious  pathological  state  of  this  organ  ;  but  of  what  use  are 
suspicions  when  we  need  authentic  facts  ? 

401.  In  the  following  observation,  the  tuberculous  affection 
was  not  the  immediate  cause  of  death,  but  in  its  commence- 
ment it  was  equally  violent  with  the  preceding,  and  this  in- 
duces us  to  give  it  a  place  here. 


THIRTY- FOURTH     OBSERVATION. 

A  TEACHER  of  the  piano,  aet.  46,  of  middle  height,  strong 
constitution,  with  a  large  chest  and  moderate  embonpoint, 
was  admitted  into  the  hospital  of  La  Charité,  October  6th, 
1823  ;  he  had  been  ill  three  weeks.  This  affection  had  com- 
menced without  any  evident  cause,  after  having  partaken  of  a 
moderate  repast,  with  rigors,  soon  followed  by  heat,  which  last 
had  continued  from  that  time.  After  the  first  four-and-twenty 
hours  the  breathing  became  oppressed  ;  the  dyspnœa  continu- 


358  SYMPTOMS. — ACUTE  PHTHISIS  ;  [Part  11, 

ally  increased,  and  there  was  occasional  cough.  During  the 
last  eight  days  the  thirst  was  very  urgent  with  loss  of  appe- 
tite ;  no  unpleasant  feeling  at  the  epigastrium  ;  no  nausea, 
vomiting  or  diarrhœa. 

October  7th.  Expression  of  uneasiness  combined  with  in- 
difference ;  answers  questions  slowly  ;  headache  ;  movements 
of  the  thorax,  limited  and  frequent  ;  great  oppression  ;  cough, 
rare,  some  mucous  and  frothy  expectoration  ;  respiration, 
weak,  without  râle,  under  the  right  clavicle,  natural  every 
where  else  ;  heat  of  the  skin,  moderate  ;  pulse,  eighty  ; 
tongue,  yellowish  in  the  centre,  natural  on  the  edges  ;  ano- 
rexia ;  little  thirst  ;  sense  of  heat  with  dryness  in  the  phar- 
ynx ;  deglutition,  easy  ;  no  epigastric  pain  ;  constipation. 

(Infusion  of  violets  with  gum  syrup  ;  gum  potion  with 
oxyrael  ;  emollient  injection). 

The  sputa  becoming  slightly  viscous,  he  was  bled  the  next 
day  to  §  X.  9th.  Expectoration,  rather  easier  ;  dyspnœa,  as 
before  ;  no  change  in  percussion  or  auscultation  ;  tongue, 
rather  red  on  the  edges  ;  painful  sense  of  heat  and  dryness  in 
the  pharynx,  which,  as  well  as  the  tonsils,  was  of  a  bright 
red;  deglutition,  difficult;  thirst,  moderate;  heat,  considera- 
ble ;  pulse,  one  hundred  and  four.  Blood  of  the  preceding 
evening,  covered  by  a  slight  greyish  layer,  about  a  line 
thick. 

(Pectoral  infusion  with  oxymel  ;  gum  potion  with  §  ss.  of 
the  oxymel  of  squills  ;  blister  five  inches  square  to  the  anterior 
part  of  the  chest). 

The  next  day  the  heat  of  the  surface  was  diminished  ; 
pulse,  rather  less  frequent.  11th.  Sputa,  rather  viscous, 
white,  spumous  ;  respiration,  as  on  tlie  9th.  No  crepitation 
could  be  detected,  and  percussion  was  every  where  clear  ; 
pulse,  rather  weak,  ninety-six  ;  pharynx  and  tonsils  as  before; 


Chap.  8.]       DEATH  FROM  PNEUMONIA.  359 

the  uneasiness  increased  ;  the  movements  became  difficult 
and  uncertain  ;  two  liquid  stools. 

(Demulcent  gargle). 

12th.  Pulse,  less  frequent  ;  expression  of  prostration  ; 
speaks  slowly  ;  the  uvula  was  infiltrated  ;  be  still  complained 
of  the  heat  and  dryness  in  the  pharynx  and  along  the  neck. 
No  change  on  the  following  day.  14th.  A  kind  of  bellows 
sound  (bruit  de  soufflet)  was  heard  over  a  great  part  of  the 
chest;  expectoration,  viscous,  white  or  greyish  ;  pulse,  very 
quick;  tongue,  hard,  dry,  and  cracked.  Heat  of  the  pharynx, 
the  same  ;  its  redness  and  that  of  the  uvula  rather  less  ;  in- 
creased anxiety,  with  general  redness  of  the  face.  Some  deliri- 
um in  the  night,  and  the  next  morning,  at  ten,  a.  m.  he  expired. 

There  were  daily  two  liquid  stools  ;  profuse  perspirations 
of  the  head  during  the  night  ;  the  abdomen  was  never 
painful. 

Opening  of  the  corpse  twenty-two  hours  after  death. 

Exterior.  — Nothing  worth  notice,  save  that  the  muscular 
system  was  well  developed. 

Head.  —  Considerable  sub-arachnoidean  infiltration  ;  the 
upper  cerebral  veins  were  distended  ;  pia  mater,  moderately 
injected  ;  brain,  very  firm,  and  firmly  injected  ;  a  spoonful  of 
clear  fluid  in  each  lateral  ventricle. 

Neck.  —  Amygdalae,  healthy  ;  uvula,  a  little  thickened  ; 
partial  destruction  of  the  epiglottis  on  the  left  side,  for  the 
space  of  two  lines  long,  rather  less  broad  ;  mucous  membrane 
of  the  larynx,  natural  ;  that  of  the  trachea,  of  a  bright  red  in- 
feriorly,  and  of  good  consistence. 

Thorax.  —  Lungs,  voluminous,  dark  colored  ;  the  left  was 
free,  the  right,  partially  adherent.  Their  tissue  was  red,  and 
granulated  over  the  greater  part  of  their  extent,  easily  broken 


360  SYMPTOMS.  —  ACUTE  PHTHISIS  ;  [Part  II, 

down,  especially  that  of  the  right  ;  it  was  firmer  at  the  sum- 
mit than  at  the  base,  and  yielded  when  pressed  a  dark  colored 
fluid,  which  was  mingled  with  a  little  air  inferiorly  ;^tbere 
were  numerous  grey,  semi-transparent  granulations,  which 
diminished  in  size  from  above  downwards.  They  were  opaque 
and  yellowish  in  their  centre,  and  above  they  were  of  the  size 
of  a  hemp  seed,  below  as  large  as  a  millet  seed,  the  latter  of 
which  were  wholly  semi-transparent  The  bronchia  were  thin  ; 
their  mucous  membrane,  healthy,  with  the  exception  of  a 
slight  livid  tint,  such  as  we  frequently  find  in  patients  whose 
respiration  had  been  difficult  for  some  time  before  death. 
Heart,  rather  soft  ;  the  aorta  presented  some  yellowish  patches. 
Abdomen.  —  Round  ulcerations  of  about  a  line  in  diam- 
eter through  the  whole  length  of  the  oesophagus  ;  the  corres-- 
ponding  mucous  membrane  was  destroyed.  Stomach,  volumi- 
nous ;  lining  membrane,  of  an  orange-red  color,  rather  softened 
in  one  half  of  the  great  cul-de-sac,  and  thinned  in  some  por- 
tions of  the  same  region  ;  it  was  elsewhere  uneven,  mamillated, 
greyish,  and  presented  some  indentations,  from  one  to  two 
inches  long  by  a  line  wide,  where  the  membrane  had  only 
one  fourth  the  thickness  it  possessed  in  the  mamillated  portion. 
Duodenum,  rather  red,  without  other  alteration.  Small  in- 
testine healthy,  with  the  exception  of  one  submucous  abscess, 
about  the  size  of  a  pea  ;  the  lining  membrane  of  the  large 
intestine  was  equally  healthy,  except  in  being  slightly  red  in 
spots  ;  the  liver  was  soft  and  of  a  tawny  color  ;  spleen,  rather 
large.     The  other  viscera  were  natural. 

402.  Whatever  may  have  been  the  day  on  which  the 
pneumonia  commenced,  the  patient  evidently  died  in  conse- 
quence of  it,  and  not  of  phthisis  ;  but  we  think  that  at  one 
period  tubercles  were  alone  present  in  the  lungs,  that  they 


Chap.  8.]        DEATH  FROM  PNEUMONIA.  361 

were  the  cause  of  the  first  febrile  symptoms,  and  that  their 
development  was  acute  ;  and  the  pneumonia  may  perhaps  be 
considered  the  result  of  their  rapid  formation.  In  fact,  from  the 
7th  to  the  11th  inclusively,  that  is,  until  the  fourth  day  before 
death,  the  respiratory  m.urmur  was  natural  on  the  left  side  of  the 
chest,  rather  feeble  on  the  right,  and  nowhere  was  there  acrep- 
itous  or  other  râle.  Had  there  existed  at  this  period  some 
central  portion  of  the  lung  attacked  with  pneumonia,  the  respi- 
ration on  the  surface  would  have  been  rather  increased  than 
diminished.  Besides,  an  inflammation  of  so  limited  a  descrip- 
tion would  not  explain  the  violence  of  the  symptoms  or  the  in- 
tensity of  the  dyspnœa  ;  percussion  was  universally  clear  on 
the  day  after  the  entrance  of  the  patient,  and  on  the  11th  of 
October  ;  the  hepatization  was  every  where  at  the  same  de- 
gree of  development,  and  seemed  to  have  taken  place  simulta- 
neously in  every  part  of  the  lung.  For  all  these  reasons,  we 
cannot  suppose  pneumonia  to  have  originated  earlier  than  the 
fourth  day  preceding  death  ;  therefore  the  fever,  dyspnoea,  and 
cough,  anterior  to  this  period,  were  owing  to  the  very  rapid 
development  of  tubercles.  This  really  formidable  commence- 
ment, and  its  resemblance  to  what  occurred  in  the  preceding 
observation,  induce  us  to  conclude  that  if  the  pneumonia  had 
not  been  rapidly  fatal,  the  tuberculous  affection  itself  would 
have  been  so. 

It  cannot  be  supposed  that  when  the  fever  and  dyspnœa 
commenced,  tubercles  had  already  been  in  the  lungs  for  a 
time  ;  for  before  the  appearance  of  the  pulmonic  symptoms  the 
patient  was  in  perfect  health,  and  it  is  difficult  to  imagine  such 
numerous  granulations  to  be  present  without  some  derangement 
of  the  pulmonary  functions  ;  so  that  every  thing  indicates  that 
the  tubercular  affection  was  here  extemely  rapid. 
x2 


362  SYMPTOMS.  —  ACUTE  PHTHISIS  ;         [Part  II, 

403.  The  inflammatory  condition  of  the  larynx  and  the 
ulcerations  of  the  œsophagus  doubtless  increased  the  patient's 
anxiety  and  uneasiness,  and  it  is  to  the  latter  of  these  lesions 
that  we  refer  the  inconvenient  sensation  complained  of  in  the 
neck. 

404.  We  have  hitherto  considered  the  mamillated  state  of 
the  gastric  mucous  membrane,  when  combined  with  a  greyish 
color  (94),  as  the  result  of  chronic  inflammation  ;  this  con- 
dition was  very  prominent  in  the  instance  before  us,  and  yet 
thirty  days  before  death  the  patient's  health  seemed  excellent. 
Is  this  alteration  compatible  witli  a  somewhat  healthy  state  of 
the  digestive  functions,  or  is  it  sometimes  capable  of  being 
rapidly  produced  ? 

405.  Among  the  examples  of  acute  phthisis  we  shall  in- 
clude the  following  observations,  in  which,  however,  the  pro- 
gress of  the  disease  was  rather  less  violent  and  rapid  than 
in  the  preceding  cases. 


THIRTY-FIFTH    OBSERVATION. 

A  TAILOR,  set.  19,  of  middle  stature  and  moderately  strong 
constitution,  entered  the  hospital  of  La  Charité,  May  4th, 
1824.  He  had  been  subject  to  colds  during  a  few  previous 
winters,  had  never  been  seriously  indisposed,  and  dated  his 
present  illness  twenty  days,  having  ceased  his  occupation  the 
last  four.  At  the  commencement,  cough,  clear  expectoration, 
sensibility  to  cold  ;  anorexia  ;  constipation  ;  these  symptoms 
continued,  increased  in  intensity  diiring  the  last  eleven  days, 
and  were  associated  with  pains  in  the  left  side  of  the  chest, 
principally  near  the  shoulder,  with   headache  andlassitude. 


Chap.   8.]  FATAL     IN    FIFTY    DAYS.  363 

On  the  fifteenth   day  there   were  diarrhœa  and  complete  loss 
of  appetite.    Patient  took  no  nourishment  afterwards. 

May  5th.  Face,  hot,  red,  animated  ;  eyes,  brilliant,  lively  ; 
headache  ;  lying  on  back,  though  he  can  lie  in  any  position  ; 
oppression,  moderate,  little  cough  ;  expectoration,  like  frothy 
saliva.  On  the  left  side  there  was  pain  under  the  edge  of  the 
false  ribs,  and  percussion  was  dull  in  the  lower  half  of  the  same 
side  of  the  chest,  and  anteriorly  under  the  clavicle  ;  gurgling 
very  distinct  in  the  latter  region,  and  opposite  the  shoulder 
there  was  incomplete  segophony.  On  the  right  side  auscul- 
tation and  percussion  gave  only  negative  results.  Pulse, 
ninety,  moderately  full  ;  tongue,  moist,  natural  on  edges,  with 
a  yellowish-grey  coat  in  the  centre  ;  mouth,  clammy  ;  thirst, 
urgent  ;  no  appetite  ;  epigastrium  and  hypogastrium,  sensible 
to  pressure  ;  three  liquid  stools. 

(Infusion  of  violets  ;  gum  potion  ;  V.  S.    |  x.) 

6th.  Same  symptoms  ;  the  blood  drawn  on  the  day  pre- 
vious, had  a  coagulum  without  bufl'  or  cup. 

The  same  symptoms  continued  constantly  and  almost  uni- 
formly increased  up  to  the  4th  of  June,  when  death  took 
place.  The  dyspnœa  was  urgent  and  breathing  very  rapid  dur- 
ing the  last  eight  days  only.  Towards  the  middle  of  May  the 
patient  referred  all  her  dyspnœa  to  the  left  side  of  the  chest. 
Cough,  sometimes  violent,  but  usually  moderate  ;  the  expec- 
toration was  somewhat  copious,  clear,  frothy,  whitish,  some- 
what spotted  with  blood  on  the  1st  day  of  June,  and  soon 
it  became  greenish,  but  not  striated  towards  the  last.  May 
14th.  Percussion,  perfectly  flat  on  the  left  side  below  the 
mamma  and  over  the  two  inferior  thirds  of  the  chest  posteri- 
orly ;  the  œgophony  heard  about  the  shoulder  changed  to  a 
simple  resonance  of  the  voice,  which  soon  extended  lower 
down;    the  gurgling  continued    with   occasional    cracklings. 


364  SYMPTOMS. —  ACUTE  phthisis;         [Part  II, 

26th.  Tracheal  respiration  under  the  left  clavicle,  without 
pectoriloquy.  28th.  Slight  crepitation  anteriorly  on  the  same 
side.  Pulse,  always  accelerated,  generally  not  less  than  one 
hundred,  but  it  was  nriuch  quicker  the  last  eight  days.  Heat, 
elevated  ;  rather  copious  night  perspirations,  but  rarely  chills. 
The  tongue  retained  its  first  appearance  ;  thirst,  urgent,  pro- 
portionate to  the  febrile  symptoms  ;  no  appetite  ;  epigastrium, 
rather  painful  the  first  six  days  ;  afterwards  not  so.  From  the 
22d  to  the  24th  of  May,  some  clear  vomitings,  without  bitter- 
ness. Two  or  three  liquid  stools  daily,  rarely  with  colic  pains. 
The  debility  rapidly  increased,  and  the  pain  in  the  side  hav- 
ing been  once  overcome,  the  patient  complained  of  nothing 
save  that  he  did  not  recover  his  strength.  He  was  not  anxious 
about  his  condition  except  during  the  last  few  days  of  life.  At 
this  time  he  lay  constantly  on  the  right  side  ;  his  debihty  pre- 
vented the  exploration  of  the  chest  after  the  28th  of  May,  be- 
fore which  the  respiration  was  natural.  During  the  last  week  the 
patient's  face  was  constantly  of  a  deep  red  color,  and  sometimes 
it  was  of  a  crimson  hue.  Some  deafness  and  delirium  the  day 
preceding  death. 

June  4th.  During  the  visit  the  intelligence  was  clear;  thirst, 
most  urgent  ;  and  whilst  su jSfering  extreme  dyspnœa  ;  he  drunk 
rapidly  and  without  assistance  ;  perspiration,  very  copious  ; 
and  at  eleven,  a.  m.,  he  expired. 

He  continued  the  use  of  the  drinks  first  prescribed.  Some 
thin  broth  was  occasionally  taken  ;  he  was  bled  a  second  time 
on  the  10th  of  May  ;  and  twelve  leeches  were  applied  to  the 
anus,  with  a  blister  to  the  left  side  of  the  chest  on  the  same 
day,  without  any  apparent  relief.  On  the  31st  the  dyspnœa, 
heat  of  the  skin,  and  frequency  of  the  pulse  induced  a  repeti- 
tion of  the  bleeding,  which  produced  only  a  momentary  relief. 


Chap.  8.]  FATAL    IN    FIFTY    DAYS.  365 

Opening  of  the  corpse  twenty  hours  after  death. 

Exterior. — Considerable  emaciation.  Considerable  thin- 
ning and  almost  total  destruction  of  the  skin  in  the  middle  of 
the  blister  on  the  chest. 

Head.  — Brain,  firm,  rather  injected;  a  spoonful  of  serous 
fluid  in  each  lateral  ventricle,  and  a  spoonful  and  a  half  in 
the  occipital  fossae.  In  other  respects  the  encephalon  was 
healthy. 

Neck.  —  Cervical  glands,  red,  voluminous  and  firm  ;  some 
of  them  contained  miliary  tubercles.  Laryngeal  surface  of 
the  epiglottis,  slightly  ulcerated,  with  a  pufiy  state  of  the  sub- 
mucous tissue  ;  larynx,  natural  ;  mucous  membrane  of  the 
trachea,  of  a  bright  red,  especially  at  its  lower  part,  of  normal 
thickness  and  consistence,  with  some  small  ulcerations  which 
seemed  as  if  made  with  an  instrument. 

Thorax.  —  The  left  lung  filled  exactly  the  cavity  of  the 
pleura  ;  it  adhered  to  the  diaphragm  by  means  of  a  false  mem- 
brane ;  it  was  merely  lying  upon  the  pleura  over  the  rest  of  its 
extent,  and  was  firm  and  resisting  every  where  except  for  the 
space  of  about  an  inch  and  a  half  at  its  anterior  edge.  At  its 
summit  there  was  a  half  emptied  cavity  about  the  size  of  a  nut, 
with  numerous  tubercles,  and  some  isolated,  hepatized  portions 
of  lung  ;  the  remainder  of  the  whole  lung  was  almost  entirely 
converted  into  crude  tuberculous  matter,  disposed  in  masses 
of  variable  dimensions,  between  which  there  was  scarcely  a 
tenth  of  the  parenchyma  permeable  to  the  air.  The  pleura 
resting  immediately  upon  the  tuberculous  matter  could  be 
easily  separated  from  it.  The  right  lung  was  free,  with  nu- 
merous tubercles  at  its  summit,  many  of  which  were  softened 
or  half  excavated  ;  they  were  confined  to  this  portion  of  the 
lung  ;  the  thin  edges  of  the  upper  and  middle  lobe  were  hep- 


366  SYMPTOMS.  —  ACUTE  PHTHISIS  ;  [Part  11, 

atized  to  a  considerable  extent.    The  left  ventricle  of  the  heart 
rather  enlarged  ;  aorta,  natural. 

Abdomen. — Stomach,  of  moderate  volume;  its  mucous 
membrane,  red  and  softened  in  the  great  cul-de-sac,  and  be- 
low, over  a  space  of  four  or  five  square  inches,  it  was  pearl- 
colored,  thin,  and  as  soft  as  mucus  ;  in  the  same  portion  the 
submucous  vessels  were  very  evident  ;  in  the  rest  of  its  extent 
it  was  mamillated,  more  or  less  red,  of  normal  consistence,  and 
one  twenty-fifth  of  an  inch  thick.  In  the  small  intestine,  near 
the  cascum,  there  were  some  semi-cartilaginous  granulations, 
some  of  which  were  ulcerated  ;  also  some  small  ulcerations, 
from  one  to  two  lines  in  diameter,  with  flattened  edges,  and 
seven  others  about  an  inch  in  surface  ;  all  situated  upon  the 
patches.  Where  these  ulcers  existed,  the  corresponding  sub- 
mucous tissue  was  denuded,  uneven,  thickened,  and  here  and 
there  destroyed  ;  elsewhere  the  mucous  membrane  was  healthy. 
That  of  the  caecum  and  ascending  colon  was  soft  ;  the  large 
intestine  was  every  where  else  natural.  The  mesenteric 
glands,  corresponding  to  the  ulcerations  were  voluminous, 
more  or  less  red,  and  spotted  with  numerous  miliary  tuber- 
cles ;  liver,  healthy  ;  bile,  dark  colored,  thick  ;  spleen,  volu- 
minous and  softened  ;  the  other  viscera  were  natural. 

406.  Up  to  the  period  of  the  invasion  of  the  cough  and 
fever,  there  was  no  functional  derangement,  so  that  we  must 
refer  the  commencement  of  phthisis  in  this  instance  to  that 
date  ;  it  was  fatal  in  fifty  days.  It  is  true,  the  lungs  were  not 
the  only  organs  affected  ;  but  if  we  reflect  that  the  left  was 
almost  entirely  transformed  into  tuberculous  matter,  and  that 
the  right  also  contained  a  certain  quantity,  it  will  be  allowed 
that  if  death  could  have  been  accelerated  by  any  compli- 
cations, they  must  have  existed  but  a  very  short  time  before 


Chap.   8.]  FATAL    IN    FIFTY    DAYS.  367 

death  ;  so  that  we   may  regard  it  as  the  effect  of  the  tubercu- 
lous affection  of  the  lungs. 

407.  It  is  not  so  easy  to  point  out  the  relative  influence  of 
the  principal  affection,  and  of  its  complications  in  the  produc- 
tion of  the  febrile  phenomena.  Auscultation,  indeed,  proved 
that  the  inflammation  of  the  substance  of  the  lung  occurred 
only  towards  the  close  of  life,  and  thus  its  influence  upon  the 
general  symptoms  was  not  exerted  except  a  short  time  before 
death  ;  but  we  cannot  affirm  that  the  inflammation  of  the  gas- 
tric mucous  membrane  did  not  commence  at  the  same  time 
with  the  cough,  although  we  think  it  probable  that  it  did  not 
date  more  than  four  days  previous  to  the  patient's  admission 
into  the  hospital.  At  this  period,  in  fact,  the  anorexia  be- 
came complete,  and  the  epigastric  pains  were  not  present  until 
some  days  afterwards.  This,  however,  may  appear  doubtful, 
so  that  the  observation  before  us  is  not  a  distinct  example  of 
the  general  symptoms  which  accompany  acute  phthisis. 

408.  When  we  first  saw  the  patient  there  was  slight  aego- 
phony  opposite  the  left  shoulder;  beneath  this,  percussion  was 
perfectly  flat,  and  there  was  no  resonance  of  the  voice,  which 
made  us  suppose  there  was  an  effusion  circumscribed  by  adhe- 
sions. But  after  death  we  found  neither  fluid,  nor  false  mem- 
branes, nor  adhesions  ;  it  is,  therefore,  impossible  to  give  any 
explanation  of  the  asgophony,  unless  we  admit  of  circumscribed 
effusions  without  false  membranes,  or  a  cause  for  aegophony 
very  different  from  effusion. 

409.  However  this  may  be,  the  absence  of  aegophony  be- 
low the  shoulder  on  the  twentieth  day  of  the  affection,  in  a 
point  where  percussion  was  dull,  and  where  we  found  the  lung 
transformed  into  tuberculous  matter,  proves  that  this  transfor- 
mation already  existed  at  that  time  ;  we  can,  therefore,  scarce- 
ly doubt  that  the  tuberculous  matter  was  developed  almost  at 


368  SYMPTOMS.  —  ACUTE  PHTHISIS  ;         [Part  II, 

once  throughout  the  whole  of  the  left  lung  ;  a  very  rare  cir- 
cumstance, and  one  which  may  be  considered  as  peculiar  to 
acute  phthisis. 

410.  Around  the  softened  and  thinned  portion,  the  gastric 
mucous  membrane  was  red,  thick,  and  mamillated.  If  this  last 
condition  depends,  as  we  have  every  reason  to  believe  it  does, 
on  inflammation,  the  other  most  probably  had  the  same  origin. 
Let  us  also  remark,  that  the  ulceration  of  the  epiglottis  gave 
rise  to  no  symptom  ;  though  we  frequently  asked  the  patient 
if  he  felt  pain  in  this  region,  a  negative  answer  was  always 
returned. 


THIRTY-SIXTH     OBSERVATION. 

411.  A  WASHERWOMAN,  8et.  23,  of  a  pretty  strong  con- 
stitution, born  of  healthy  parents,  not  liable  to  colds,  entered 
the  hospital  November  11th,  1821.  The  catamenia  had  been 
suppressed  dnring  the  eleven  previous  months,  and  with  the 
exception  of  some  unpleasant  sensations,  which  returned  from 
time  to  time,  and  a  slight  debility,  her  health  was  never 
disturbed.  She  said  that  she  had  been  ill  fifteen  days.  Her 
affection  had  commenced  by  great  oppression,  and  after  eight 
days,  an  acute  pain  came  on  in  the  left  side  of  the  chest,  with 
cough,  expectoration,  great  heat,  especially  at  night,  anorexia 
and  thirst  ;  these  symptoms  were  preceded  during  some  days 
by  diarrhœa. 

November  12th.  Acute  pain  in  the  left  side  of  the  chest, 
increased  by  cough,  inspiration  and  decubitus  on  the  same 
side  ;  cough,  frequent,  often  dry  ;  expectoration,  frothy, 
whitish  ;  pulse,  rather  quick  ;  heat,  increased  at  night  ;  tongue, 


Chap.  8.]  FATAL    IN    FORTY-EIGHT    DAYS. 


369 


moist,  greyish  in  the  centre  ;  thirst  ;  anorexia  ;  three  liquid 
stools  without  colic. 

(Infusion  of  violets  with  oxymel  ;  gum  potion  ;  twelve 
leeches  to  the  labia  ;  poultice  to  the  chest.) 

Shortly  after  the  application  of  the  leeches,  the  pain  of  the 
chest  diminished  and  completely  ceased  ;  the  patient  could 
lie  on  either  side. 

14th.  The  skin  was  less  hot;  the  expectoration  mucous, 
yellowish  and  rather  viscid  ;  the  cough  was  very  severe  in 
the  evening  ;  it  was  the  same  the  next  day  ;  the  pain  in  the 
side  did  not  return,  and  there  was  a  little  appetite.  16th.  Ex- 
pression, less  animated  than  usual;  expectoration,  more  liquid. 
17th.  Respiration,  not  hurried  ;  pulse,  a  liitle  accelerated  ;  skin, 
mildly  warm,  nearly  natural  ;  night  sweats  ;  four  liquid  stools. 

(V.S.   §x.) 

From  the  17th  to  the  24th  the  febrile  excitement  was  very 
slight  ;  the  pulse  was  nearly  calm  ;  the  cough,  less  frequent  ; 
sputa,  rare,  thin  ;  daily  perspirations  ;  diarrhœa  less  than 
usual  ;  appetite,  increased  ;  the  food  was  increased  gradually 
to  a  quarter  of  the  house  allowance,  and  the  patient  complain- 
ed merely  of  being  unable  to  recover  her  strength. 

In  the  night  of  26th  she  vomited  her  drink,  and  in  the 
morning  complained  of  a  bitter  taste  in  her  mouth  ;  the  appe- 
tite became  less  ;  the  epigastrium  was  not  painful  ;  the  pulse 
was  accelerated  ;  there  was  slight  heat  of  the  skin. 

(Food  diminished.) 

The  same  symptoms  continued  the  following  days,  and 
during  the  night  of  the  1st  of  December,  after  a  copious  per- 
spiration, she  was  attacked  with  a  violent  rigor,  much  cough  and 
dyspnoea,  followed  by  a  deep  pain  under  the  sternum.  In  the 
morning  the  sputa  were  white  and  spumous  ;  the  face  livid, 
with  great  general  depression. 
Y  2 


370  SYMPTOMS.  —  ACUTE  phthisis;  [Part  II, 

(Blister  to  the  sternum.) 

These  symptoms  continued  to  increase  up  to  the  15th  of 
December,  when  death  took  place.  7th.  Mucous  râle  with 
a  kind  of  gurgling,  was  heard  under  the  left  clavicle.  11th. 
Same  results  from  auscultation,  with  percussion  flat  in  the 
same  points.  The  voice  suddenly  became  extinct,  and  contin- 
ued so  to  the  last;  no  annoying  sensations  in  the  larynx.  The 
pain  under  the  sternum  was  felt  sometimes  during  the  cough. 
4th.  Sputa,  greyish,  rounded  and  opaque  ;  they  retained  these 
characters  until  death  ;  diarrhœa  during  the  last  ten  days. 
The  patient  said  nothing,  complained  of  nothing,  and  usually 
lay  on  the  left  side,  apparently  absorbed  by  the  feelings  of 
oppression. 

Opening  of  the  corpse  forty  hours  after  death. 

Exterior.  —  Moderate  emaciation  ;  brain,  not  exam- 
ined. 

Neck.  — Larynx,  natural  ;  lining  membrane  of  the  trachea 
and  bronchia,  of  a  somewhat  bright  red  color. 

Thorax.  —  Right  lung,  free,  without  tubercles,  and  engorg- 
ed at  its  base.  The  left  presented  some  cellular  adhesions  at 
its  summit,  was  free  elsewhere,  and  there  was  no  trace  of  false 
membranes.  The  upper  lobe  was  almost  entirely  composed 
of  tuberculous  matter,  every  where  softened  almost  uniformly, 
and  contained  three  cavities,  which  were  incompletely  emptied  ; 
the  tuberculous  matter  was  divided  into  numerous  masses,  be- 
tween which  there  was  a  certain  quantity  of  the  grey,  semi- 
transparent  matter.  The  lower  lobe  presented  a  small  num- 
ber of  tubercles,  and  was  engorged  at  its  base.  Heart,  of  a 
proper  size  ;  its  parietes  were  a  little  thicker  than  usual  ; 
aorta,  healthy. 

Abdomen.  —  The  stomach  was  not  more  voluminous  than 


Chap.  8.]  FATAL    IN    FOKTY-EIGHT    DAYS.  371 

the  colon  ;  its  mucous  membrane  was  pale.  There  were 
twelve  ulcerations,  from  one  to  two  lines  in  diameter,  in  the 
small  intestine.  Liver,  voluminous,  fatty,  and  of  a  tawny 
color;  the  kidneys  were  of  a  livid  red;  uterus,  normal;  the 
ovaries  of  usual  volume,  but  containing  a  small  quantity  of 
tuberculous  matter. 

412.  Let  us  rapidly  examine  the  principal  circumstances  of 
this  observation.  The  catamenia  had  been  suppressed  ten 
months,  during  which  time  there  had  been  slight  uneasiness 
at  the  usual  periods,  but  neither  fever,  emaciation,  oppression, 
nor  cough  ;  in  a  word,  no  symptoms  which  could  be  referred 
to  an  affection  of  the  lungs.  We  cannot,  therefore,  date  the 
origin  of  the  tubercles  farther  back  than  the  invasion  of  the 
dyspnoea,  so  that  the  affection  lasted  forty-eight  days,  and 
was  probably  the  only  cause  of  death  ;  for  notwithstanding  the 
incomplete  description  of  the  gastric  mucous  membrane,  yet 
from  its  paleness,  the  absence  of  nausea,  vomiting  and  epigas- 
tric pains,  we  may  regard  it  as  healthy.  The  prompt  termi- 
nation of  the  disease  is  rather  remarkable,  since  there  were  no 
tubercles  in  the  right  lung,  and  those  in  the  left  were  almost 
entirely  confined  to  the  upper  lobe  of  the  left  lung. 

413.  But  the  principal  peculiarity  in  this  observation  is  its 
remittent  character.  In  fact,  after  some  days  of  oppression, 
the  patient  is  attacked  with  fever,  cough,  expectoration,  and 
acute  pain  in  the  left  side  of  the  chest  ;  these  symptoms  con- 
tinue with  more  or  less  intensity,  eight  or  ten  days,  and  then 
yield  partially  to  the  application  of  leeches  to  the  labia  ;  at  least 
the  pain  ceased  and  the  other  symptonjs  diminished  ;  and  after 
a  general  bleeding  of  ten  ounces,  the  fever  almost  completely 
disappeared  ;  the  cough  diminished  ;  the  expectoration  became 
less  copious,   and   the   digestive  functions  improved.      This 


372  SYMPTOMS.  —  ACUTE  PHTHISIS  ,'  [Part  II, 

amendment  lasted  eleven  days,  and  during  the  night  of  the 
1st  of  December,  the  patient  was  seized  with  rigor,  oppression, 
and  anxiety  ;  the  cough  was  frequent,  and  death  unexpectedly 
took  place  on  the  thirteenth  day  of  this  last  cKacerbation.  Could 
not  one  say  that  the  disease  remained  for  some  time  stationary  ? 
It  is,  however,  probable,  that  it  constantly  progressed,  and 
that  the  violence  of  the  last  attack  was  principally  owing  to 
the  sudden  softening  of  a  certain  number  of  tubercles,  and 
their  evacuation  into  the  bronchia.  It  is  certain,  at  least,  thai 
the  expectoration  underwent  a  decided  alteration  from  the 
moment  the  symptoms  became  formidable. 

414.  The  pain  felt  in  the  left  side  at  the  commencement 
renders  this  observation  analogous  to  the  preceding,  and  shows 
that  when  tuberculous  matter  is  rapidly  developed,  it  can  oc- 
casion more  or  less  suffering.  In  neither  case  were  there  any 
traces  of  recent  pleurisy.  However,  it  is  possible  that  as  the 
tuberculous  matter  was  developed  immediately  under  the 
pleura,  the  pain  might  still  be  owing  to  this  membrane. 

415.  In  the  four  observations  we  have  just  detailed,  the 
commencement  of  the  disease  was  more  or  less  violent,  and 
death  took  place  from  thirty  to  fifty  days,  in  the  midst  of  more 
or  less  local  and  general  symptoms.  There  was  no  haemop- 
tysis ;  cough  and  expectoration  sometimes  preceded  the  dys- 
pnœa,  which  last  fact  approximates  these  cases  to  those  in 
which  phthisis  is  much  less  rapid  in  its  course,  and  is  latent 
during  a  certain  period,  giving  rise  only  to  general  phenomena. 

416.  But  the  number  of  our  observations  is  too  limited  to 
justify  any  general  description  of  acute  phthisis,  or  to  allow  us 
accurately  to  d^ilineate  the  diagnostic  signs  of  its  first  stage. 
We  think,  however,  the  disease  ought  to  be  dreaded,  in 
those  cases  where  dyspnoea,  cough,  expectoration,  fever,  with 


Chap.  S.]  SUMMARY.  373 

sometimes  pain  of  the  chest  and  very  hurried  respiration  come 
on  suddenly  and  without  evident  cause  ;  and  where  these 
symptoms  persist  and  increase,  notwithstanding  the  treatment 
we  oppose  to  them,  while  the  characteristic  signs  of  pneu- 
monia, pleurisy,  and  severe  suffocating  bronchitis,  are  wanting. 
Our  diagnosis  may  be  assisted  by  the  careful  practice  of  aus- 
cultation and  percussion.  Should  we  find  percussion  obscure 
exclusively  under  the  clavicle,  and  the  respiratory  murmur 
feeble,  or  in  any  way  altered,  when  symptoms  such  as  we 
have  described  are  present,  we  may  consider  the  existence  of 
unsoftened  tubercles  as  certain.  But  notwithstanding  this 
combination  of  symptoms  and  the  positive  results  of  ausculta- 
tion and  percussion,  doubts  might  still  be  entertained  as  to  the 
nature  of  the  disease  in  the  first  stage,  if,  as  was  the  case  in  the 
thirty-fifth  observation,  the  tuberculous  matter  should  be  simul- 
taneously developed  throughout  the  whole  extent  of  one  lung. 
For,  under  these  circumstances,  the  dulness  of  sound  at  the 
inferior  and  posterior  part  of  the  chest  might  favor  the  idea  of 
pneumonia,  although  in  front  the  dulness  of  sound  should  be 
limited  to  a  small  space  in  the  subclavicular  region.  The 
change  in  the  expectoration  at  the  commencement  of  the 
second  period,  the  strong  and  tracheal  respiration  where  it 
was  previously  obscure,  and  the  resonance  of  the  voice  would 
soon  remove  all  doubts. 

417.  In  the  thirty-third,  thirty-fifth  and  thirty -sixth  obser- 
vations there  were  tuberculous  excavations  in  the  summit  of 
the  lungs  ;  but  they  were  small,  incompletely  excavated,  and 
without  false  membsanes  ;  which  proves,  as  we  have  already 
remarked,  that  these  membranes  only  exist  when  the  progress 
of  phthisis  is  much  less  acute. 

418.  Notwithstanding  its  rapid  development,  secondary 
disorders  were  present,  and  similar  to  those  we  have  described 


374  SYMPTOMS.  —  ACUTE  PHTHISIS  ;  [Part  11, 

in  cases  where  the  duration  of  the  disease  was  more  chronic* 
Thus,  we  observed  ulcerations  of  the  mucous  membrane  of  the 
epiglottis  and  trachea  (Obs.  34,  35),  of  the  oesophagus  (Obs. 
34),  and  of  the  small  intestine.  In  one  case  (Obs.  35),  the 
mucous  membrane  of  the  stomach  was  softened  and  thinned  ; 
in  another  the  liver  had  undergone  the  fatty  transformation 
(Obs.  36)  ;  and  in  another  the  cervical  and  mesenteric 
glands  contained  a  small  quantity  of  tuberculous  matter  (Obs. 

35). 

419.  Three  of  the  patients  were  very  young,  eighteen, 
nineteen  and  twenty  years  of  age  ;  a  fourth,  in  whom  we  found 
only  grey,  semi-transparent  granulations,  was  in  his  forty-sixth 
year  ;  the  acute  form  was  therefore  not  confined  to  young  per- 
sons, and  perhaps  additional  facts  will  demonstrate  its  existence 
at  all  periods  of  life. 

420.  We  shall  terminate  this  article  by  the  following  ob- 
servation, which  we  should  have  mentioned  first,  were  it  not 
deficient  in  many  of  its  anatomical  details. 


THIRTY-SEVENTH     OBSERVATION. 

An  UNMARRIED  woman,  confincd  seventeen  days  since,  of  a 
pretty  strong  constitution,  and  usually  enjoying  good  health, 
entered  the  hospital  of  La  Charité,  July  13th,  1822.  Dur- 
ing her  pregnancy  lier  health  had  been  excellent,  and  for  six 
days  after  her  delivery  her  general  state  was  very  satisfactory. 
She  was  then  suddenly  and  without  any  evident  cause  attack- 
ed with  violent  cough,  accompanied   with  expectoration,  dys- 

*This  result  is  remarkable.  —  Cowan. 


Chap.  8.]  FATAL    IN    THIRTY    DAYS.  375 

pnœa,  fever,  anorexia,  and  intense  thirst.  The  lochia  were 
suppressed  and  some  abdominal  pains  succeeded.  Ten  leeches 
were  applied  to  the  epigastrium  at  the  commencement  ; 
and  she  was  bled  without  evident  relief;  these  symptoms 
continued  to  increase,  and  there  was  occasionally  nausea.  On 
the  14th  of  July,  the  left  side  of  the  chest  became  painful, 
and  on  the  15th  her  symptoms  were  the  following  — 

Some  headache,  occasional  buzzing  in  the  ears  ;  face, 
pale  ;  great  debility  ;  the  patient  required  assistance  for  every 
thing;  expression,  wandering,  but  her  answers  were  just; 
memory,  faithful  ;  decubitus,  elevated  ;  respiration,  thoracic, 
forty-three  in  the  minute  ;  the  pain  in  the  lateral  and  inferior 
part  of  the  left  side,  less  acute  than  on  the  preceding  evening; 
cough,  rather  frequent  ;  percussion,  every  where  clear  ;  pulse, 
one  hundred  and  forty  ;  heat  of  the  skin,  not  very  great  ;  no 
perspiration  ;  tongue,  moist,  rather  pale  ;  thirst  urgent  ;  ano- 
rexia ;  abdomen,  yielding  ;  pain  in  the  umbilical  region  ;  eight 
to  ten  liquid  stools  in  twenty-four  hours . 

(Infusion  of  violets;  gum  potion;  blister  to  the  anterior 
part  of  the  chest.) 

From  this  period  to  the  1st  of  August,  the  day  of  her 
death,  we  observed  the  following  : — Considerable  oppression  ; 
respiration,  frequent  (fifty  in  a  minute  on  the  23d  of  July)  ; 
cough,  moderate  ;  expectoration,  a  little  brownish,  not  viscous, 
on  the  19th  ;  it  was  viscous,  red,  or  greenish,  and  with  yellow 
streaks  on  the  23d  ;  this  continued  with  little  variation  to  the 
last.  17th.  Respiration,  natural  on  the  right  side,  feeble  on 
the  left  ;  obscure  anteriorly  on  the  18th  and  19th;  and  on 
the  last  day  associated  with  a  slight,  dry,  sonorous  râle.  On 
the  23d,  gurgling  was  heard  ;  on  the  30th,  the  respiration 
under  the  clavicle  was  tracheal.  Pulse,  irregular  for  a  short 
time  on  the  16lh  ;  it  was  small  and  one  hundred  and  thirteen 


376  SYMPTOMS.  —  ACUTE  PHTHISIS  ;         [Part  II, 

on  the  26th,  continuing  as  frequent  to  the  last  ;  heat,  always 
elevated  ;  the  tongue,  constantly  pale  and  moist  ;  it  was  at  first 
yellowish  in  the  centre,  but  a  few  days  after  entrance  it  became 
clean,  and  of  almost  natural  color  ;  no  appetite  ;  thirst,  rather 
urgent;  the  left  lumbar  region  more  or  less  painful  ;  stools,  rare; 
except  the  last  ten  days,  when  there  was  slight  diarrhoea.  Dur- 
ing the  same  period  the  abdomen  was  rather  tympanitic.  The 
patient  appeared  very  uneasy,  not  speaking  except  to  answer 
questions.  On  the  23d  she  said  she  had  no  pain  ;  from  the 
22d  to  the  25th  there  was  some  numbness  in  the  right  arm 
On  the  26th,  she  complained  of  an  acute  pain  in  the  shoulder 
of  the  same  side  if  she  made  the  slightest  movement  ;  the 
movements  of  the  right  leg  were  also  difficult  and  painful. 
On  the  20th,  it  became  oedematous  and  more  painful  ;  the 
patient  seemed  to  apprehend  her  danger,  and  thought  herself 
dying  of  consumption.  31st.  Expression,  rather  more  ani- 
mated than  usual  ;  she  died  at  four,  a.  m.,  the  following 
morning. 

Opening  of  the  corpse  twenty-seven  hours  after  death. 

Exterior.  —  Emaciation  not  very  considerable  ;  slight 
œdema  of  the  lower  extremities  without  vibices. 

Head.  —  Sub-arachnoidean  infiltration  much  more  consid- 
erable to  the  left  than  to  the  right  ;  brain,  lateral  ventricles, 
&;c.,  natural. 

Thorax. — A  pint  of  serous  fluid  in  the  right  pleura  ;  the  lung 
of  the  same  side  was  a  little  engorged,  but  free  from  tubercles  ; 
the  left  lung  was  every  where  covered  by  a  false  membrane, 
forming  adhesions  to  the  costal  pleura,  much  less  dense  at  the 
base  than  at  the  summit  of  the  lung.  Between  these  two  ex- 
tremes the  layers  were  separated,  and  enclosed  about  a  quart 
and  a  half  of  thick  pus  ;  the  lung  was  soft  and  rather  heavier 


Chap.  8.J  FATAL    IN    THIRTY    DAYS.  377 

than  the  right,  containing  numerous  small  abscesses  communi- 
cating with  each  other,  but  not,  as  far  as  we  could  detect, 
with  the  bronchia.  They  were  about  the  size  of  a  filbert, 
separated  by  a  variably  thick  layer  of  sound  lung,  and  filled 
with  thick  pus,  slightly  greyish  in  the  centre,  and  very  thick 
at  its  circumference.  Elsewhere  there  was  no  trace  of  either 
tuberculous,  grey,  or  semi-transparent  matter.  The  bronchia 
were  thin  and  of  a  pale  pink  tinge.  Heart,  flaccid  ;  right  ven- 
tricle rather  larger  than  the  left,  with  the  parietes  only  one 
line  thick;  the  aorta,  of  a  bright  red  color,  which  gradually 
faded  in  the  large  ramifications  ;  crural  veins  filled  with  coag- 
ulated blood. 

Abdomen.  —  A  pint  of  fluid  in  the  pelvis;  liver,  of  mod- 
erate volume,  tawny,  and  rather  adipous  ;  spleen,  twice  its 
usual  size,  of  a  dull  red  color  and  much  softened  ;  gastric  mu- 
cous membrane,  red  and  softened  in  a  portion  of  the  great 
cul-de-sac,  elsewhere  healthy  ;  mucous  membrane  of  the 
small  intestine,  natural  ;  that  of  the  large  intestine,  of  a  bright 
red  and  very  soft  ;  uterus,  augmented  in  volume  and  softened  ; 
its  internal  surface  was  of  a  brown  red  color,  in  contact  with  a 
sanguineous  fluid  ;  it  presented  a  reticulated  appearance  ;  in 
one  portion,  which  was  prominent,  and  which  doubtless  cor- 
responded to  the  attachment  of  the  placenta,  it  was  easily 
removed,  and  formed  a  layer  of  about  a  line  thick.  The 
vaginal  parietes  were  red,  and  on  the  left  side  presented  a 
perforation  of  half  an  inch  in  diameter,  opening  into  an  abscess 
lying  on  the  iliac  bone. 

421.  When  the   patient   was    admitted  into  the  hospital, 
there  was  no  evident   emaciation  ;  her   muscular  system  was 
well  developed  ;  in  short,  every  thing  indicated  a  recent  affec- 
tion ;  our  reiterated  questions  as  to  the  state  of  her  health 
z  2 


378  SYMPTOMS.  —  ACUTE  PHTHISIS.  [Part  II, 

during  pregnancy,  were  always  answered  by  her  saying,  she 
was  perfectly  well,  and  that  the  cough  and  the  other  symp- 
toms had  come  on  six  days  after  lying-in  ;  so  that  we  must 
admit  that  the  left  lung  underwent  the  alteration  we  have 
described  in  the  space  of  one  month. 

422.  The  condition  of  the  lung  has  been  incompletely 
noted  ;  we  have  omitted  to  indicate  the  structure  of  the  small 
abscesses,  and  it  may  be  questioned  whether  they  were  not 
the  result  of  some  other  affection  than  the  tuberculous.  If 
dilatation  of  the  bronchia  (and  we  think  we  have  only  to 
choose  between  this  lesion  and  tuberculous  excavations)  was 
the  cause  of  the  appearance,  the  disease  must  certainly  have 
been  chronic,  the  communications  of  the  principal  bronchial 
divisions  easy  to  be  established,  and  the  contents  of  the  cavities 
thin.  But  in  this  case  the  disease  was  recent,  and  we  could 
not  discover  any  communication  with  the  bronchia,  and  they 
were  dense  exteriorly,  all  which  characters  are  not  unusual  in 
a  tuberculous  affection.  Although  the  communication  be- 
tween the  cavities  and  bronchia  was  not  demonstrable  after 
death,  the  cavernous  râle  which  existed  during  life  seems  to 
have  indicated  its  existence  ;  we  must  also  recollect  the  adi- 
pous  state  of  the  liver,  which  we  have  seen  is  almost  confined 
to  phthisis  (161).  We  may  then  regard  this  observation  as  an 
example  of  acute  phthisis,  passing  through  its  different  stages 
in  thirty  days.  It  is  remarkable  that  out  of  five  cases  of  this 
affection,  in  two  it  was  limited  to  one  side  of  the  chest. 

423.  We  shall  offer  no  remarks  on  the  majority  of  the 
complications  which  were  present,  only  recalling  the  pains 
and  weakness  of  the  right  side  of  the  body,  when  some  bloody 
sub-arachnoidean  infihration,  more  at  the  right  side  than  at 
the  left,  was  the  only  encephalic  alteration.  Is  there  any 
connexion  between  this  lesion,  and  especially  the  unequal  dis- 
tribution of  the  fluid  and  the  symptoms? 


Chap.  9.]  PERFORATION    OF    THE    LUNG.  379 


CHAPTER   IX. 

SYMPTOMS  OF  PERFORATION  OF  THE  LUNG  BY  A  SOFTENED 
TUBERCLE  DISCHARGING  ITSELF  INTO  THE  PLEURAL 
CAVITY. 

424.  This  species  of  perforation  pointed  out  by  Laennec, 
presents  itself  under  two  principal  divisions  ;  in  one,  a  com- 
munication is  established  between  the  pleural  cavity  and  the 
bronchia  in  the  other,  this  is  not  the  case.  In  both,  the  mo- 
ment of  perforation  is  marked  by  very  serious  and  character- 
istic symptoms  which,  when  well  marked,  render  our  diag- 
nosis, if  not  certain,  at  least  extremely  probable.  We  shall 
prove  this  assertion  in  the  following  observations.* 


THIRTY-EIGHTH     OBSERVATION. 

A  MAN,  set.  36,  of  small  stature  and  impetuous  character, 
was  admitted  into  the  hospital  of  La  Charité,  September 
16th,  \822.  He  had  quitted  a  few  days  before  the  prison  of 
Poissy,  where  he  had  been  confined  five  months,  having  con- 
tracted soon  after  his  arrival  a  cold,  which  had  made  continual 

*  The  first  four  observations  of  this  chapter  have  been  already  published 
in  our  researches  on  various  diseases  ;  subsequent  experience  having  only 
confirmed  the  results  contained  in  our  first  work.  We  have,  as  it  were, 
changed  them  in  no  respect,  except  that  we  have  introduced  some  points  in 
detail  which  were  suppressed  in  the  observations,  and  we  have  given  them 
the  form  adopted  throughout  this  work.  —  Louis. 


380   SYMPTOMS. PERFORATION  OF  THE  LUNG  ;  [Part  II, 

progress.  Emaciation  had  commenced  with  the  cough,  and 
during  two  months  he  experienced  daily  rigors,  epigastric 
pains,  with  fluid  and  frequent  stools.  Three  days  before  en- 
tering the  hospital,  he  was  attacked  suddenly,  after  having 
vomited  on  account  of  being  exposed  to  the  fumes  of  burning 
charcoal,  with  a  violent  pain  in  the  left  side,  accompanied 
with  dyspnœa,  and  great  anxiety  ;  after  twenty-four  hours  the 
violence  of  the  symptoms  somewhat  abated.  On  the  third  day 
from  their  invasion,  the  patient,  who  resided  about  three  hun- 
dred paces  from  the  hospital,  came  there  on  foot  having  occu- 
pied an  hour  and  a  half  in  so  doing.  The  next  day  the  pain  and 
anxiety  being  still  considerable,  twenty  leeches  were  applied  to 
the  chest.  Two  days  afterwards  (19[h),  face  was  pale,  fatigu- 
ed ;  his  breathing  thoracic  and  frequent,  with  orthopnoea  ;  acute 
pain  ;  percussion  unusually  clear  over  the  whole  of  left  side, 
more  clear  than  on  the  right,  and  no  respiration  could  be  heard 
there,  either  in  inspiration  or  expiration,  nor  any  metallic  tink- 
ling ;  the  intercostal  spaces  were  prominent  and  wide  ;  cough 
rare,  some  nummulated  sputa  ;  pulse,  one  hundred  and  twenty  ; 
action  of  heart  scarcely  audible  in  the  precordial  region  ;  mouth, 
clammy  ;  thirst,  urgent  ;  very  little  appetite  ;  sense  of  weight 
in  the  epigastrium  after  food  ;  pain  on  pressure  in  the  same 
region,  which  has  been  the  case  for  the  last  two  months. 

(V.  S.  §  X.  ;  infusion  of  violets;  with  gum  syrup;  gum 
potion  ;  julep.) 

20th.  Symptoms  nearly  the  same  ;  fresh  application  of 
leeches  to  the  left  side,  which  was  three  quarters  of  an  inch 
larger  than  the  right  ;  the  next  day  a  blister  was  applied. 
25th.  Pulse,  down  to  ninety-two  ;  the  dyspnœa  variable, 
sometimes  very  urgent  ;  decubitus,  as  before  ;  left  side  still 
increases  without  any  change  in  auscultation  and  percus- 
sion. 


Chap  9.]       DYSPNŒA  ;  pain  ;  percussion  clear.         381 

There  was  but  a  slight  change  in  the  symptoms  during  the 
following  days.  The  patient  dishking  examination,  ausculta 
tion  was  not  again  practised  until  the  5th  of  October.  In  the 
upper  fourth  of  the  left  lung,  there  was  then  a  confused  mur- 
mur, and  opposite  the  inferior  angle  of  the  scapula,  when  the 
patient  spoke,  there  was  metallic  tinkling.  In  the  same  point, 
and  lower  down,  the  sound  on  percussion  was  dull  ;  anteriorly 
it  was  clearer  tlian  natural,  but  here  there  was  no  metallic 
tinkling  ;  the  pain  had  ceased  ;  the  left  arm  was  œdematous. 
On  the  7th,  the  metallic  tinkling  was  heard  five  inches  below 
the  axilla,  and  nearly  every  where  on  the  same  side  of  the 
chest  posteriorly,  On  the  8th,  it  was  evident  immediately 
under  the  axilla.  On  the  13th,  it  was  heard  in  the  same 
region  and  on  a  level  with  the  mamma  ;  inferiorly,  percussion 
was  perfectly  flat.  On  the  20th,  percussion  was  very  clear 
between  the  clavicle  and  mamma  ;  the  metallic  tinkling  was 
no  where  heard.  Cough,  not  very  frequent;  expectoration, 
scanty.  On  the  21st  it  was  sanious,  and  resembled  what  is 
often  found  in  tuberculous  excavations.  The  patient  remain- 
ed constantly  in  the  sitting  posture.  The  appetite  was  ex- 
ceedingly variable  ;  epigastrium,  always  painful  on  pressure, 
and  the  lightest  food,  soup,  &c.  caused  a  sense  of  weight  in 
the  same  region  ;  stools,  more  or  less  frequent  ;  little  perspi- 
ration ;  daily  increase  of  weakness.  The  infiltration  of  the 
left  arm  continued  until  death.  8th.  Erysipelas  in  the  elbow 
joint,  which  went  through  its  usual  stages  as  if  no  complica- 
tion existed.  18th.  Some  slight  redness  and  swelling  of 
thighs;  the  next  day  these  symptoms  were  increased.  21st. 
Great  alteration  of  the  expression,  and  he  expired  at  three, 
p.  M.,  on  the  thirty-third  day  from  the  origin  of  the  symptoms 
which  indicated  perforation. 


382         SYMPTOMS. PERFORATION    OF    THE    LUNG;    [Pai't  II, 

Opening  of  the  corpse  seventeen  hours  after  death. 

Exterior. —  Considerable  infiltration  of  the  lower  ex- 
tremities, especially  on  the  left  side,  where  the  inguinal  glands 
were  redder  and  more  voluminous  than  on  the  right.  On  the 
left  arm,  where  the  erysipelas  had  occurred,  the  skin  was  still 
rather  red,  about  a  line  thick,  and  lying  on  a  layer  of  concrete 
pus,  more  than  half  an  inch  in  depth,  which  was  deposited  in 
the  midst  of  infiltrated  serum. 

Head.  —  Moderate  infiltration  beneath  the  arachnoid  ; 
three  small  spoonsful  of  serum  in  the  lateral  ventricles. 

Neck.  —  A  superficial  ulceration,  one  inch  in  length  and 
half  an  inch  wide,  on  the  lower  part  of  the  muscular  portion 
of  the  trachea. 

Thorax.  —  On  the  left  side  there  were  nearly  four  quarts 
of  greenish-colored  pus,  free  from  odor,  surmounted  by  a  small 
quantity  of  air.  The  lung  presented  some  cellular  adhesions 
at  its  summit,  and  was  invested  elsewhere  by  a  false  mem- 
brane, which  lined  the  diaphragmatic  and  costal  pleural.  The 
lung  was  flattened  against  the  vertebral  column,  about  two 
inches  and  a  half  in  its  thickest  portion,  presenting  posteriorly, 
opposite  the  angle  of  the  third  rib,  a  rounded  opening,  four 
lines  in  diameter,  the  termination  of  a  canal  of  the  same  dimen- 
sions, which,  after  an  inch  and  a  half,  was  continuous  with  one 
of  the  large  bronchia.  This  canal  was  lined  by  a  membrane 
which  reposed  either  on  tuberculous  granulations  or  healthy 
lung,  and  evidently  resulted  from  a  larger  cavity,  successively 
narrowed  by  the  compression  of  the  air  and  pus.  There  were 
some  small,  incompletely  excavated  cavities  in  the  summit  of 
the  same  lung,  with  numerous  grey,  semi-transparent  granula- 
tions. The  right  lung  presented  superiorly  a  depression  cor- 
responding to  a  semi-cartilaginous  mass,  enveloped  by  a  black 


Chap.  9.]  dyspnœa;  sudden  pain,  &c.  383 

and  dry  substance  with  some  softened  tubercles.  The  mu- 
cous membrane  of  the  bronchia  was  of  a  bright  red.  Some 
ounces  of  serum  in  the  pericardium.  Heart  and  aorta,  nat- 
ural. 

Abdomen.  —  Stomach,  somewhat  distended  by  fluid;  its 
lining  membrane  was  exceedingly  soft  in  the  great  cul-de-sac, 
where  it  presented  some  red  spots,  and  in  the  lower  portion 
of  the  sanie  region,  over  a  surface  of  two  inches,  it  was  de- 
stroyed, and  the  cellular  layer  was  gone  in  some  points.  Else- 
where the  consistence  and  thickness  were  normal.  In  the  last 
quarter  of  the  small  intestine  there  were  three  large  annular 
ulcerations,  with  numerous  very  small  ones  in  their  intervals, 
and  tuberculous  granulations,  some  of  which  were  ulcerated  at 
their  summit.  The  mucous  membrane  of  the  large  intestine 
was  everywhere  softened,  and  presented  some  ulcerations  in 
the  ascending  colon.  The  liver  and  pancreas  were  natural  ; 
the  spleen  vvas  very  soft  and  voluminous. 


THIRTY-NINTH    OBSERVATION. 

425.  A  SEMPSTRESS,  set.  45,  of  a  pretty  strong  constitution, 
although  constantly  subject  to  difficult  digestion,  had  been  ill 
fifteen  days  when  she  was  admitted  into  La  Charité,  June 
4th,  1824.  Her  illness  had  commenced  with  cough,  expec- 
toration, and  a  pretty  copious  hagmoptysis,  which  lasted  eight 
days,  and  had  since  been  frequendy  repeated,  especially  dur- 
ing the  last  four  months.  From  the  same  period  the  dyspnœa 
had  become  considerable  ;  she  had  frequent  pains  in  the  sides 
of  the  chest  ;  almost  constant  rigors  and  perspirations  ;  she 
had  lost  her  flesh   and   appetite,    and   vomited   nearly  every 


384  SYMPTOMS.  PERFORATION    OF    THK    MJNG  ;     [Part  II, 

thing  she  took.  For  three  months,  epigastric  pains,  frequent 
colics,  with  mucous  and  bloody  stools  were  associated  with 
the  preceding  symptoms.  She  had  not  kept  her  bed  nor 
ceased  her  occupation.  9th.  Some  emaciation  ;  skin,  rather 
yellow  ;  headache  ;  pains  in  the  limbs  ;  expectoration,  frothy, 
white  or  greenish,  semi-opaque.  Under  the  left  clavicle, 
where  the  pains  had  been  almost  constant  for  three  months, 
percussion  was  perfectly  flat  ;  the  respiration  was  tracheal, 
and  pectoriloquy  very  distinct  over  three  inches  of  surface  ; 
below  this  there  was  some  cavernous  râle.  On  the  right  side 
the  respiration  seemed  natural.  Appetite,  feeble  ;  tongue, 
moist,  and  of  a  good  color  ;  cold  drinks  insupportable  ;  epigas- 
trium very  sensible  to  pressure,  offering  a  resistance  to  the 
hand,  which  extended  along  the  right  false  ribs. 

(Decoction  of  polygala,  with  quince  syrup  ;  julep  ;  three 
rice  creams.) 

On  the  following  days  there  was  rather  copious  diarrhoea,  and 
from  the  18th  to  the  20th,  constant  nausea,  with  complete 
anorexia.  A  gum  potion  with  syrup  of  poppies  was  prescrib- 
ed, and  after  three  days  the  symptoms  abated,  the  appetite 
returned,  and  she  was  soon  able  to  eat  one  fourth  of  the  house 
allowance,  with  only  a  slight  sense  of  weight  in  the  epigas- 
trium ;  about  the  same  results  obtained  from  percussion  and 
auscultation.  July  20th,  at  eleven,  a.  m.,  when  free  from 
suffering,  she  was  attacked  with  jjain  near  the  inferior  angle 
of  the  scapula,  which  was  at  first  moderate,  then  suddenly 
very  violent,  with  dyspnœa,  anxiety,  continual  cough,  and 
orthopnœa.  These  symptoms  did  not  abate  during  the  night, 
and  the  pain  frequently  seemed  to  extend  from  the  back  over 
the  v.'hole  of  the  chest,  as  far  as  the  umbilicus,  again  returning 
to  the  back. 

In  the  morning  the  respiration  was  extremely  difficult,  the- 


Chap.  9.]  DYSPNOEA  ;  sudden  pain,  &;c.  385 

racic,  and  fifty-two  in  the  minute  ;  the  patient  said  she  was 
suffocating,  and  that  no  posture  was  easy  ;  the  face  was  altered 
without,  however,  having  an  expression  of  intense  suffering  ; 
the  pain  in  the  back  was  acute,  and  the  shghtest  percussion 
on  the  right  side  of  the  chest  was  insupportable;  the  per- 
cussion was  much  clearer  on  the  right  than  the  left  side, 
even  when  attempted  at  the  most  sonorous  part  of  the  former  ; 
respiratory  murmur,  absent  there,  except  posteriorly  and  supe- 
riorly ;  no  metallic  tinkling  ;  pulse,  regular,  extremely  small 
and  weak,  a  hundred  and  twenty-eight  ;  constant  palpitations. 
All  these  symptoms  persisted  ;  the  anxiety  increased  ; 
there  was  no  change  in  auscultation,  and  after  intense  suffer- 
ing, sometimes  interrupted  by  a  transitory  stupor,  she  expired 
on  the  23d,  at  twelve,  m,,  three  days  after  the  commencement 
of  the  pain. 

Opening  of  the  corpse  twenty-eight  hours  after  death. 

Exterior. — Considerable  emaciation.  Nothing  else  re- 
markable. 

Head.  —  Some  arachnoidean  granulations  on  both  sides  of 
the  longitudinal  fissure  ;  pretty  thick  sub-arachnoidean  infil- 
tration ;  cortical  substance  of  the  brain,  rather  pink. 

Neck.  —  Larynx  and  trachea,  natural. 

Thorax.  • —  An  incision  made  into  the  right  side  of  the 
chest  gave  vent,  with  some  noise,  to  an  inodorous  gas  ;  the  pleu- 
ra, which  lined  the  dorsal  region,  was  covered  by  a  soft  false 
membrane,  in  contact  with  four  ounces  of  turbid  fluid.  The 
lung  occupied  rather  less  than  one  third  of  the  thoracic  cavity, 
and  adhered  for  about  three  inches  to  the  surrounding  parts, 
by  means  of  a  false,  semi-cartilaginous  membrane,  half  a  line 
thick.  Immediately  below  this  adhesion  posteriorly,  there 
A  3 


386  SYMPTOMS.  PERFORATION   OF  THE   LUNG  ;    [Part  11, 

was  a  rounded  opening,  three  lines  in  diameter,  communica- 
ting with  a  sm-all  cavit}-,  lined  by  a  very  thin  false  mem- 
brane resting  upon  healthy  pulmonary  tissue.  This  small 
cavity  did  not  conimnnicate  either  with  the  bronchia,  nor 
with  a  very  large  excavation  just  above  it,  which  was  in- 
vested by  a  double  false  membrane,  the  inner  layer  of 
which  was  soft,  the  other  semi-cartilaginous.  In  the  three 
lower  fourths  of  this  lung  there  were  only  some  grey,  semi- 
transparent  granulations.  The  left  lung  adhered  to  the  costal 
pleura  in  its  upper  half,  and  presented  at  its  summit  a  large 
excavation,  communicating  with  the  bronchia,  and  also  with 
numerous  small  cavities  ;  in  the  two  upper  thirds  there  were 
numerous  grey  granulations,  surrounded  by  a  yellowish,  moist, 
semi-transparent  substance,  firm,  homogeneous,  and  entirely 
deprived  of  air  ;  the  remainder  of  the  organ  was  red  and  hep- 
atized.  The  bronchia  were  of  a  bright  red  color.  Two 
ounces  of  serum  in  the  pericardium  ;  heart  sound. 

Abdomen. — The  liver,  voluminous,  uneven,  deeply  grooved 
at  the  right  of  the  suspensory  ligament,  rather  red,  especially 
in  the  right  lobe  ;  it  covered  the  stomach,  and  extended  nearly 
to  the  umbilicus.  The  stomach  was  contracted  ;  its  internal 
surface  was  nearly  every  where  covered  by  mucus,  presenting 
near  the  cardia  a  white  space  about  four  inches  in  surface,  where 
the  lining  membrane  was  extremely  thin,  pale,  and  soft  as  mu- 
cus ;  whilst  the  surrounding  portion  was  mamlUated,  pink- 
colored  and  thickened  to  the  right  ;  very  thin  and  of  a  bright 
red  to  the  left.  Near  the  pylorus  were  numerous  red  bands, 
one  inch  long  by  three  lines  wide,  where  the  mucous  mem- 
brane was  thin  and  depressed.  In  the  small  intestine  this 
membrane  was  red  and  injected,  but  of  normal  thickness  and 
consistence  ;  in  the  colon  it  was  red,  softened,  and  with  small 
ulcerations. 


Chap.  9.]  ACUTE    DYSPNŒA  ;    ANXIETY,    &c.  387 


FORTIETH    OBSERVATION. 

426.  A  woMANj,  aet.  32,  tall  and  strong,  entered  the  hos- 
pital of  La  Charité,  Sept.  11th,  1823.  She  had  constant- 
ly coughed  and  expectorated  the  last  eleven  months,  with 
frequent  haemoptysis  and  pains  between  the  shoulders  ;  rigors, 
followed  by  heat  and  perspiration,  with  epigastric  pains,  were 
present  fvon  the  commencement.  Her  breathing  had  been 
affected  for  a  long  time. 

The  day  after  admission  the  expression  was  animated  ; 
headache  ;  speaks  hurriedly,  with  occasional  aphonia  ;  atti- 
tude, easy  ;  respiration,  natural,  except  on  the  right  side  pos- 
teriorly and  superiorly,  where  it  was  rather  tracheal  ;  some 
dyspnœa  ;  expectoration,  greenish;  no  pectoriloquy;  pulse, 
rather  quick  ;  heat  elevated  ;  tongue,  clean  and  moist  ;  appe- 
tite, depressed  :  pain  on  pressure  in  the  epigastrium  ;  consti- 
pation. 

(Infusion  of  Iceland  moss  ;  pectoral  ptisan  ;  gum  potion  with 
syrup  of  poppies;  emollient  enema  ;  one  eighth  of  the  house 
allowance.) 

From  that  time  to  the  20th  of  December,  when  she  ex- 
pired, the  following  is  the  result  of  our  observations  :  —  In  the 
beginning  of  October  the  patient  complained  of  great  heat 
between  the  shoulders  ;  there  was  resonance  of  the  voice  and 
traclieal  respiration  in  the  same  point  and  under  both  clavi- 
cles, especially  the  right  ;  percussion,  every  where  clear;  ex- 
pectoration, puriform. 

December  4th.  Doubtful  pectoriloquy  between  the  shoul- 
ders and  under  the  left  clavicle  ;  gurgling  in  the  same  point, 
over  a  space  of  six  inches.      In  the  night  of  the  19th,  some 


388  SYMPTOMS.  PERFORATION  OF  THE  LUNG  ;    [Part  11, 

acute  pains  were  felt  in  the  back  ;  in  the  morning  these  had 
diminished,  without  any  evident  increase  of  dyspnœa.  The 
following  night  she  was  attacked  by  a  violent  and  sudden  pain 
along  the  vertebral  column,  accompanied  with  dyspnoea  and 
anxiety.  The  next  morning  the  patient  was  in  the  sitting 
posture,  spoke  only  of  her  pain  and  difficulty  of  breathing,  and 
assured  us  of  the  suddenness  of  the  attack  ;  the  countenance 
was  altered,  and  percussion  was  clearer  to  the  left,  posteriorly 
and  laterally,  than  on  the  right  side.  Over  the  same  extent, 
instead  of  the  respiratory  murmur,  there  was  only  a  mucous 
râle,  which  appeared  to  traverse  an  empty  space  before  arriv- 
ing at  the  ear  ;  there  was  no  metallic  tinkling  ;  and  on  the 
patient's  lying  down  and  rapidly  rising,  no  peculiar  sound  was 
heard  ;  the  breathing  was  very  frequent,  with  great  agitation  ; 
she  expired  at  ten  o'clock  the  same  evening,  after  intense 
suffering.  The  heat  was  constantly  elevated,  and  the  night 
perspirations  copious.  These  were  unsuccessfully  treated 
during  two  months,  by  the  aqueous  infusion  of  bark,  in  doses 
of  from  eight  to  ten  ounces  a  day. 

In  the  beginning  of  October  the  appetite  w^as  feeble  ;  there 
was  a  bitter  taste  in  the  mouth  ;  the  tongue  was  whitish  ;  there 
were  occasional  vomitings  during  the  paroxysms  of  the  cough  ; 
these  were  present  with  a  still  greater  anorexia  and  a  natural 
state  of  the  tongue,  on  the  4th  of  December.  On  the  10th, 
the  thirst  was  more  urgent  ;  all  drinks  produced  a  sense  of 
weight  in  the  epigastrium  ;  during  several  days  there  was  con- 
siderable diarrhœa.  The  emaciation  was  rather  rapid,  and  on 
the  4th  of  December  the  left  arm  was  œdematous. 

Opening  of  the  corpse  thirty-four  hours  after  death. 

Exterior.  —  Considerable  oedema  of  the  left  arm.  Noth- 
ing else  remarkable. 


Chap.   9.]  ACUTE    DYSPNŒA  J    ANXIETY,    SlC.  389 

Head.  —  Three  small  spoonfuls  of  serum  in  the  lateral 
ventricles.     The  remainder  of  the  encepalon,  healthy. 

Neck.  —  Trachea  and  larynx,  natural. 

Thorax.  — Only  a  small  quantity  of  gas  escaped  from  the 
left  side,  which  contained  about  three  quarts  of  a  sanguinolent 
fluid,  without  any  fragments  of  albumen.  A  soft  membrane, 
ofa  deep  red  color,  and  one  quarter  of  a  line  thick,  every 
where  invested  the  lung  and  thoracic  parietes.  The  summit 
of  the  lung,  for  two  inches  and  a  half,  was  intimately  adherent 
to  the  neighboring  parts;  and  almost  immediately  beneath  this 
adhesion  posteriorly  there  was  a  rounded  opening,  about  the 
size  ofa  pea,  communicating  with  a  vast  excavation,  contain- 
ing a  very  small  quantity  of  a  greyish  fluid,  similar  to  what  was 
in  contact  with  the  diaphragm.  This  cavity  communicated 
with  the  bronchia.  The  upper  five  sixths  of  the  lung  were 
transformed  into  an  indurated,  greyish,  semi-transparent  sub- 
stance, interspersed  with  numerous  tubercles  and  small  exca- 
vations ;  these  communicated  with  each  other,  and  in  some 
points  were  separated  by  a  very  thin  layer  only  from  the  tho- 
racic cavity  ;  the  lower  sixth  of  the  lung  was  crepitating  ;  the 
bronchia  were  of  a  pale  pink  color.  There  were  some  exca- 
vations in  the  summit  of  the  right  lung,  and  at  its  base  some 
crude  tubercles  ;  heart,  one  third  less  than  its  usual  volume  ; 
aorta,  every  where  ofa  bright  red. 

Abdomen.  —  Stomach,  larger  than  usual  ;  lining  membrane 
of  a  pale  rose  color  in  some  parts  ;  mamillated  anteriorly  and 
in  a  portion  of  the  great  cul-de-sac  ;  in  the  same  points  it  pre- 
sented some  ulcerations,  from  two  to  six  lines  in  diameter  ;  in 
the  rest  of  hs  extent  it  was  of  normal  consistence  and  thick- 
ness. In  the  small  intestine  there  was  much  mucus,  but  its 
membrane  was  pale  and  firm,  and  in  the  lower  fifth  some  ellip- 
tical patches  were  ulcerated  ;  the   mucous   membrane  of  the 


390  SYMPTOMS.  PERFORATION  OF  THE  LUNG  ;    [Part  II, 

large  intestine  was  pale  ;  the  ulcerations  diminished  in  fre- 
quency on  approaching  the  rectum,  where  only  one  existed. 
The  liver  was  soft,  easily  torn  ;  the  bile  rather  fluid,  and  not 
high  colored  ;  spleen,  a  little  softened  ;  cortical  substance  of 
the  kidneys  much  redder  and  moister  than  usual  ;  pancreas, 
indurated  ;  uterus,  healthy. 


FORTY-FIRST     OBSERVATION. 

427.  A  WOMAN,  ast.  26,  of  a  feeble  constitution  and  ex- 
treme sensibility,  entered  La  Charité,  November,  15th,  1823  ; 
she  had  lost  her  flesh  the  last  two  years,  which  she  ascribed  to 
mental  anxiety.  Though  little  liable  to  taking  cold,  she  had 
constantly  coughed  and  expectorated  during  the  last  five  months, 
and  during  the  first  fifteen  days  of  the  pulmonary  affection, 
was  sensible  of  fever,  with  headache,  much  oppression,  and 
the  expectoration  was  occasionally  bloody  ;  the  symptoms 
were  subsequently  much  milder.  During  the  last  six  weeks 
her  appetite  had  almost  ceased,  and  she  had  frequent  colic, 
also  rigors,  followed  by  heat  and  night  perspirations. 

Nov.  16th.  Expression,  rather  animated  ;  considerable 
weakness,  with  marked  emaciation  ;  voice,  feeble,  husky,  the 
last  two  months  ;  cough,  frequent  ;  expectoration,  greenish, 
imperfectly  nummulated  ;  respiratory  murmur,  weaker  in  the 
upper  half  of  the  left  side  than  in  the  right,  in  the  correspond- 
ing part;  elsewhere,  the  respiration  was  natural,  and  no  reso- 
nance of  voice  nor  pectoriloquy  could  be  detected  ;  heat,  mod- 
erate ;  pulse,  one  hundred  ;  and  the  preceding  evening  her 
usual  rigors,  followed  by  heat,  had  returned  at  eleven,  p.  m. 
Tongue,  rather  red  on  the  edges,  villous  and  yellowish  in  the 


Chap.  9.]  ACUTE  PAIN  ;  faintness  ;  dyspnœa,  &ic.       391 

centre  ;  appetite,  diminished  ;  epigastrium,  yielding  ;  the 
right  lumbar  region  resisting,  without  evident  tumor  ;  stools, 
regular. 

(Pectoral  ptisan  ;  infusion  of  Iceland  moss  ;  one  fourth  of 
the  house  allowance.) 

The  febrile  paroxysms  incommoding  the  patient,  the  sul- 
phate of  quinine  was  employed  ;  but  on  account  of  the  un- 
easiness, vertigo,  epigastric  pains,  &;c.,  which  followed  its 
administration,  it  was  suppressed  on  the  27th.  The  rigor 
had  ceased,  though  the  heat  returned  at  the  usual  hour. 

December  4th.  Tracheal  respiration  under  the  left  clavicle  ; 
constipation  ;  almost  complete  anorexia  ;  return  of  the  rigors. 
On  the  following  days  the  cough  provoked  nausea,  and  the 
constipation  was  succeeded  by  copious  diarrhosa. 

In  the  night  of  the  1st  of  January,  she  experienced  sudden- 
ly a  sensation  in  the  left  side  of  the  chest,  similar  to  what 
would  have  been  caused  by  the  circulation  of  a  gas  from  be- 
low upwards  in  this  same  part;  the  breathing  at  the  same 
time  became  very  difficult  ;  there  was  a  tendency  to  fainting, 
and  almost  immediately  afterwards  a  very  acute  pain  behind 
the  left  mamma.  In  the  morning  this  pain  continued;  it  was 
deeply  situated  ;  the  breathing  was  much  more  hurried,  and 
the  patient  was  obliged  to  lie  on  the  right  side;  much  general 
uneasiness  ;  the  sensation  of  the  presence  of  gaseous  fluid  no 
longer  existed.  On  the  left  side  the  chest  resounded  like  a 
drum  ;  no  respiiation  nor  metallic  tinkling  could  be  heard  ; 
the  aphonia  was  complete  ;  face  pale  ;  lips  discolored,  and  the 
patient  was  threatened  with  syncope  if  she  attempted  to  sit 
up  ;  pulse,  feeble,  small,  one  hundred  and  sixteen. 

The  state  of  the  respiration  having  been  accurately  ob- 
served up  to  the  16th  of  January,  the  result  of  our  observa- 
tions was  the  followinii  :  —  4th.  Under  the   left  axilla  some 


392  SYMPTOMS.  —  PERFORATION  OF  THE  LUNG  ;    [Part  IT, 

very  weak  respiration,  with  slight  mucous  râle  under  the  clav- 
icle of  the  sanae  side.  5th.  xMetallic  tinkling  two  inches  below 
the  clavicle  when  the  patient  spoke.  7th  and  following  days, 
it  extended  more  over  the  chest,  and  was  caused  by  inspira- 
tion as  well  as  speaking.  The  pain  becoming  more  acute, 
leeches  were  applied  on  the  evening  of  the  iOth.  The  next 
day  the  dyspnœa  was  increased,  breathing  very  hurried,  pain 
diminished,  metallic  tinkling,  as  for  some  days  past,  heard 
over  the  three  lower  fourths  of  the  chest,  which  last  gave  a 
very  clear  sound  on  percussion,  whilst  there  was  no  respiratory 
sound  there  ;  no  change  up  to  the  16th.  On  the  17th,  the 
dyspnœa  was  much  increased  ;  percussion  of  left  side  was  still 
clear.  She  expired  on  the  18th,  without  suffering,  a  few 
minutes  after  saying  to  M.  Chomel  that  she  needed  sleep. 

From  the  commencement  of  the  pneumo-thorax,  the  decu- 
bitus was  constantly  on  the  right  side  ;  the  aphonia  occasion- 
ally disappeared  ;  the  cough  was  not  generally  very  frequent; 
the  expectoration,  greenish,  nummulated  ;  pulse,  small,  weak, 
and  frequent;  there  was  little  mental  depression,  and  hope  of 
recovery  was  present  to  the  last.  There  was  no  appetite  ; 
alternately  constipation  and  diarrhœa  ;  some  mucous  vomit- 
ings for  a  (ew  days  after  the  perforation. 

Opening  of  the  corpse  twenty-three  hours  after  death. 

Exterior.  —  Nothing  remarkable  ;  considerable  emacia- 
tion.    (Brain  and  larynx  could  not  be  examined.) 

Thorax.  —  Percussion  of  the  left  side,  clear  only  anteri- 
orly ;  it  contained  rather  more  than  one  hundred  cubic  inches 
of  a  gas,  which  proved  to  be  carbonic  acid  ;  the  remainder  of 
the  thoracic  cavity  on  this  side,  that  is,  about  three  fourths, 
contained  a  turbid,  greenish  fluid.  The  right  lung"  was  scarcely 
twice  as  large  as  the  closed  hand  ;  it  was  adherent  at  its  sum- 


Chap,  9.]     ACUTE  pain;  faintness  ;  dyspnœa,  he.     393 

mit  for  about  two  inches,  and  immediately  below  this  adhe- 
sion, posteriorly,  there  was  a  rounded  opening  of  two  lines 
and  a  half  in  diameter,  with  thin  edges,  and  communicating 
with  a  cavity,  about  the  size  of  an  ordinary  apple  ;  it  was  an- 
fractuous, and  lined  by  tuberculous  fragments  lying  on  a  thin 
false  membrane,  pierced  in  several  points  by  the  orifices  of  the 
bronchia.  Below  the  perforation  there  were  numerous  yel- 
lowish patches,  corresponding  to  softened  tubercles,  on  the 
point  of  emptying  themselves  into  the  pleural  cavity  ;  the  re- 
mainder of  the  lung  was  soft,  not  containing  air,  but  some 
tubercles,  which  diminished  in  number  towards  the  base.  The 
pleura  was  every  where  invested  by  a  thin  false  membrane, 
firm  superiorly  ;  and  in  contact  with  the  diaphragm,  there  was 
a  greenish  substance,  of  a  gelatinous  consistence,  enough  to 
have  filled  an  ordinary  tumbler.  The  right  lung  presented 
some  adhesions,  with  a  small  excavation  and  tubercles  in  its 
upper  lobe.     Heart,  small  ;  aorta,  healthy. 

Abdomen.  —  The  stomach  contained  a  moderate  quantity 
of  viscous  and  yellowish  mucus  ;  the  lining  membrane  was  of 
a  tawny  color,  nearly  every  where  mamillated,  of  good  con- 
sistence, and  partially  destroyed  over  a  surface  of  two  lines  in 
length  on  the  small  curvature  ;  that  of  the  small  intestine  pre- 
sented in  its  lower  half  numerous  small  ulcerations  ;  it  was  of 
a  bright  red  color,  and  a  little  softened  near  the  ceecum,  for 
the  space  of  two  feet.  The  lining  membrane  ^of  the  large 
intestine  was  throughout  as  soft  as  mucus,  red  and  ulcerated 
in  the  ascending  colon,  with  a  light  pink  tint  over  the  other 
parts  of  it  ;  the  liver  extended  for  a  breadth  of  three  fingers 
beyond  the  ribs,  was  rather  voluminous,  of  a  dull  yellow  color 
spotted  with  red,  of  moderate  consistence  and  rather  adipous. 
Bile  of  the  gall-bladder,  pale  and  thin  ;  the  other  viscera  of 
the  abdomen  were  natural. 
B   3 


894         SYMPTOMS.  PERFORATION  OF  THE  LUNG  ;    [Part  11, 


FORTY-SECOND     OBSERVATION. 

428.  A  PORTER,  set.  26,  short,  well  made,  with  red  hair  and 
well  developed  muscular  system,  was  admitted  into  the  hospital 
November,  8th,  1824  ;  he  had  been  employed  in  the  service 
of  the  army  from  his  twelfth  to  his  twenty-fourth  year;  had 
enjoyed  good  health,  and  dated  his  present  illness  eight 
months  ;  he  had  coughed  and  expectorated  during  the  same 
period,  and  attributed  his  cold  to  the  bad  condition  of  the 
office  where  he  pursued  his  occupation.  The  cough  had 
greatly  increased,  came  on  in  paroxysms,  and  during  the  last 
five  months  the  expectoration  had  become  opaque  ;  in  the 
fourth  month,  during  fifteen  days,  he  had  experienced  acute 
pains  in  the  back,  and  these  had  been  felt  in  the  left  side  of 
the  chest  for  the  last  fortnight  ;  at  the  commencement  there 
was  no  fever,  but  for  three  months  there  had  been  increased 
heat  in  the  evenings,  with  constant  copious  perspirations  every 
night.  The  appetite  had  not  diminished,  but  the  last  two 
months  it  had  been  rather  more  urgent  than  usual  ;  bowels, 
regular.  The  emaciation  was  evident  three  months  from  the 
commencement  of  the  first  symptoms,  and  from  the  same  peri- 
od the  patient  had  ceased  his  occupations. 

November  9th.  Great  weakness  ;  little  emaciation  ;  a  slight 
intermitting  pain  in  the  left  side  of  the  chest  ;  moderate  dys- 
pnoea ;  cough,  frequent  and  in  paroxysms  during  the  night  ; 
expectoration,  scanty,  greenish,  opaque,  imperfectly  nummu- 
lated  ;  respiratory  murmur,  confused,  with  mucous  râle  and 
some  dulness  of  sound  under  the  right  clavicle,  with  resonance 
of  the  voice  post!  riorly  in  the  corresponding  point  ;  on  the 
left  side  the  respiration  was  weak  posteriorly.     Pulse,  slightly 


Chap.  9.]        DYSPNŒA  ;  acute  pain,  &c.  395 

accelerated;  heat  and  copious  perspiration  lastnijrht;  appe- 
tite, good  ;  tongue,  clean  ;  abdomen,  not  painful  ;  stools,  rare  ; 
patient  calm. 

(Infusion  of  Iceland  moss  ;  gum  potion  with  a  grain  of 
opium  in  the  evening;   a  quarter  of  the  house  allowance.) 

20th.  Immediately  under  the  right  cla^icle  it  seemed  as  if 
a  small  pufFof  air  entered  the  stethoscope  when  the  patient 
spoke.  On  the  morning  of  the  28th,  the  sputa  presented 
some  streaks  of  blood,  and  in  the  evening  there  was  an  expec- 
toration of  about  twelve  ounces  of  blood.  This  continued 
more  or  less  until  the  8th  of  December,  and  seemed  to  di- 
minish after  the  use  of  a  gum  potion,  which  contained  a 
drachm  of  powdered  ratanhy  root,  and  it  disappeared  com- 
pletely on^  the  third  day  ;  three  bleedings  from  |  x.  to  §  xij. 
each,  with  demulcent  drinks,  had  been  previously  tried  with- 
out success.  During  the  first  four  days  of  the  haemoptysis, 
there  was  a  crepitating  râle  on  the  left  side,  every  where  pos- 
teriorly, and  in  the  lower  half  anteriorly. 

9th.  Respiratory  murmur,  nearly  natural  on  the  left  side  ; 
sputa,  white,  greenish  and  nummulated  ;  thirst,  moderate; 
pulse,  calm  ;  the  appetite,  which  for  a  time  diminished,  re- 
turned ;  there  was  no  diarrhœa  ;  dyspnoea  increased  ;  the 
cough  continued  strong  during  the  night.  There  was  little 
change  up  to  the  30th  ;  the  cough  usually  excited  pain  in  the 
left  side.  5th.  Pectoriloquy  evident  under  the  right  clavicle, 
with  slight  crepitation  in  the  lower  half  of  the  same  side  ;  it 
was  nearly  universal  on  the  left,  and  on  the  28th  it  was  con- 
fined to  this  side.  31st.  The  patient  complained  of  increased 
suffering  during  the  cough  in  the  leftside.  In  the  evening  the 
pain  became  suddenly  very  acute,  with  considerable  dyspnœa  ; 
the  next  day  the  difficulty  of  breathing  and  anxiety  were  ex- 
treme.    January  2d.  At  seven,  a.  m.,  the  patient  was  quite 


396  SYMPTOMS.  PERFORATION  OF  THE  LUNG  ;    [Part  II, 

conscious,  and  clearly  remembered  what  had  occurred  since  the 
invasion  of  the  pain,  but  already  his  sight  had  become  confused  ; 
the  face  was  bathed  in  perspiration  ;  the  dyspnœa  was  extreme, 
breathing  very  rapid;  percussion  of  chest  much  clearer  ante- 
riorly on  the  left  side  than  on  the  right.  In  the  same  region 
no  respiratory  murmur  nor  metalhc  tinkling  could  be  heard  ; 
suffocation  seemed  imminent,  and  two  hours  afterwards  she 
expired.  The  same  day,  the  expectoration  was  greyish,  of 
a  disagreeable  aspect,  like  viscid  size.  There  were  some 
pains  in  the  region  of  the  larynx. 

From  the  15th  of  December  the  heat  during  the  evening 
was  considerable  ;  perspirations,  copious  during  the  night, 
without  rigors  ;  no  chills  ;  thirst,  moderate  ;  the  appetite 
gradually  diminished  and  then  entirely  disappeared^  diar- 
rhœa  present  during  the  last  five  days  only. 

Opening  of  the  corpse  iiventy-three  hours  after  death, 

ExTEKioR.  —  Muscles,  thick,  firm,  well  colored  ;  emacia- 
tion, only  commencing. 

Head.  —  A  small  spoonful  of  serum  in  each  lateral  ven- 
tricle ;  a  spoonful  at  the  base  of  the  skull  ;  no  other  altera- 
tion. 

Neck.  —  Epiglottis  and  larynx,  natural  ;  lining  membrane 
of  the  trachea,  red,  of  normal  consistence  and  thickness,  pre- 
senting immediately  above  the  bronchial  bifurcation  two  small 
irregular  ulcerations,  from  one  third  to  a  fifth  of  an  inch  in 
surface,  with  a  thickened  state  of  the  submucous  layer  in  the 
corresponding  point. 

Thorax.  —  An  inodor<:fUs    gas  escaped,  with    ome  noise, 
through  a  small  incision  made  into  the  left  side  of  the  chest. 
There   was  a  space  of  from  two  to  three   inches  between^ 
the  lung  and  parietes  of  the  thorax,  augmenting  from  above 


Chap.  9.]  DYSPNŒA  ;  acute  pain,  &tc.  397 

downwards;  the  lung  was  fixed  by  four  whitish,  thin,  firm  bands, 
uniting  the  puhnonary  and   costal  pleuraî.     Its  base,  and  the 
corresponding  portion  of  the  diaphragm  were  lined  by  a  soft 
false  membrane,  with  a  reticulated   appearance,   thick,  and  in 
contact  with  about  twelve  ounces  of  a  pretty  clear  reddish  fluid. 
Its  upper  lobe  was  enveloped  by  another  false  membrane,  half  a 
line  thick,  and  semi-carlilaginous  ;  and   at  its  lower  portion 
there  was  a  rounded  yellow  patch,  a  line  in  diameter,  corres- 
ponding to  a  softened  tubercle,   which  had  been  partially  dis- 
charged into  the  pleural  cavity.     The   opening  was   in   part 
closed    by  a  small    quantity   of  tuberculous   matter,   and   the 
cavity  lined  by  a  thin,   soft,  light  colored  false   membrane  ; 
there  was  no  communication    with  the   bronchia.     Towards 
the  central  part  of  the  same  lobe  there  were  three  excavations, 
similar  to  the  one  we  have   described,  surrounded  by  healthy 
lung,  and  in  the  summit  two  other  smaller  ones,  as  large  as 
hazel  nuts,  surrounded  by  indurated,  greyish  tissue  where  the 
red  and  thickened  bronchia  terminated.     The  lower  lobe  was 
slightly  engorged,  and  contained  some  semi-transparent  gran- 
ulations.    The  right  lung  adhered   every  where  to  the  costal 
pleura  by  dense  cellular  membrane  ;  its  summit  was  indurated 
for  the  space  of  three  inches,  and  presented   four  excavations, 
about  the  size  of  a  cherry  filled  with  greenish  pus,  and  sur- 
rounded by  a   firm  greyish  structure  ;  this  was  intersected  by 
numerous  while,  semi-cartilaginous  or  cellular  septa,  irregular- 
ly distributed  and  exuding,  when  pressed,  a  very  small  quan- 
tity of  greyish   fluid.     The  communicating  bronchia   were  of 
a  bright  red,  and   their  mucous  membrane  thickened.     The 
lower  lobe  was  a  little  engorged,  contained  two  or  three  tuber- 
cles, and  some  isolated  portions  of  hepatized  lung,  of  the  size 
'  of  a  ruit.     The  bronchial  glands  were  grey  and  voluminous, 
not  tuberculated.     Heart  and  aorta,  healthy. 


398       srMPTOMs.  —  perforation  of  the  lung  ;  [Part  II, 

Abdomen.  — ■  Stoinacli,  twice  as  large  as  u.?ual,  reaching  a 
little  below  the  umbilicus,  and  containing  a  large  quantity  of 
viscous  mucus  ;  its  lining  membrane  was  of  a  dark  red  color 
posteriorly,  rather  soft  anteriorly,  where  its  color  was  natural. 
The  elliptical  patches  of  the  small  intestine  were  ulcerated  in 
the  lower  sixth  ;  on  them.,  likewise,  there  were  numerous 
tuberculous  granulations,  the  softening  of  which  seemed  to 
have  been  the  source  of  the  ulcerations  ;  no  other  alteration  of 
the  mucous  membrane.  In  the  ascending  colon  there  were 
six  small  greyish  ulcerations  ;  the  corresponding  cellular  tissue, 
rather  thickened,  and  here  and  there  destroyed  :  between 
these  ulcerations  there  were  others  still  smaller.  Throughout 
the  whole  of  the  large  intestine  the  lining  membrane  was  a 
little  softened  and  thickened.  The  mesenteric  glands  were 
reddish  and  voluminous,  not  tuberculated.  Spleen,  pale,  and 
nearly  twice  its  usual  volume  ;  the  other  viscera,  healthy. 


FORTY-THIUD     OBSERVATION. 

429.  A  CABINET  maker,  set.  42,  short,  of  a  feeble  constitution, 
but  usually  enjoying  good  health,  and  little  subjectt  o  cold,  said 
that  hischesthad  never  been  affected  before  the  commencement 
of  his  present  illness.  He  had  been  ill  five  months,  having  re- 
linquished his  occupations  the  last  two,  without  however  being 
confined  to  his  bed.  He  was  attacked,  without  any  evident 
cause,  by  a  rather  violent  cough,  with  clear  expectoration. 
In  the  beginning  of  the  fourth  month  this  was  combined  with 
dyspnoea  and  acute  pains  in  the  right  side,  requiring  the  appli- 
cation of  leeches  and  a  blister.  The  expectoration  had  be- 
come very  thick  the  last  three   weeks,  and  for  ten  days  the 


Chsp.  9.]  DYSPNŒA  ;  ACUTE  PAIN,  hc.  399 

cough  had  much  increased  ;  the  thirst  was  urgent,  the  heat  at 
night  augmented,  with  copious  perspirations.  The  appetite 
had  diminished  from  the  first,  and  for  twenty  days  had  ceased 
ahogether  ;  considerable  emaciation  the  last  two  months  ;  he 
has  never  had  rigors,  haemoptysis  or  diarrhœa. 

January  4th,  1S25  (the  day  after  his  admission),  the  face 
was  pale,  with  marked  emaciation  and  debility  ;  cough,  rare  ; 
dyspnoea,  moderate  ;  decubitus,  variable  ;  sputa,  greenish, 
opaque,  not  striated  ;  percussion,  less  clear  on  the  right  side 
than  the  left,  especially  in  the  lower  half  posteriorly  and  later- 
ally, where  it  was  completely  flat  ;  respiratory  murmur,  weak, 
mingled  with  a  mucous  râle  nearly  every  where  on  the  same 
side  ;  tracheal  respiration  and  pectoriloquy  at  the  summit  of 
the  right  lung  ;  it  was  less  distinct  on  the  left  side  between 
the  shoulder  and  vertebral  column.  Voice,  almost  extinct 
the  last  two  months;  no  pain,  or  dryness,  or  heat,  in  the 
region  of  the  larynx  or  trachea.  Pulse,  small,  weak,  acceler-- 
ated  ;  tongue,  moist,  whitish  in  the  centre  ;  mouth,  clammy, 
with  bitter  taste;  anorexia;  no  thirst;  epigastrium,  sensible 
to  pressure  ;  occasional  nausea  from  cough  ;  three  natural 
stools  without  colic  the  preceding  evening.  Patient  is  calm, 
and  utters  no  complaint.  There  was  no  sensible  change  on 
the  following  days  ;  the  larynx  and  trachea  were  never  painful 
and  they  were  always  insensible  to  external  pressure.  10th. 
He  complained  of  slight  pain  in  the  right  side  of  the  chest. 
On  the  13th,  during  the  night,  he  was  attacked  suddenly  with  a 
very  acute  pain  in  the  left  side,  accompanied  with  great  uneasi- 
ness and  dyspnœa.  In  the  morning  the  face  was  pale,  and  the 
expression  altered  ;  the  pain  was  rather  less  acute,  with  con- 
siderable dyspnoea  ;  decubitus,  not  very  elevated  ;  percussion, 
very  clear  over  the  whole  of  the  left  side.  We  omitted  to 
perform  auscultation  until  after  the  visit,  when  the  leeches 


400         SYMPTOMS.  —  PERFORATION  OF  THE  LUNG;    [Part  II, 

having  been  applied  directly  upon  the  painful  spot,  we  were 
unable  to  finish  our  examination.  He  died  the  same  day,  at 
four,  p.  M.,  retaining  perfect  consciousness  to  the  last. 

Opening  of  the  corpse  forti/  hours  after  death. 

Exterior. — Considerable  emaciation.  Nothing  else  re- 
markable. 

Head.  —  A  small  spoonful  of  fluid  in  the  lateral  ventricles  ; 
no  other  alteration. 

Neck.  —  Epiglottis,  natural.  Numerous  superficial  ulcer- 
ations on  the  vocal  cords,  and  for  about  three  lines  below 
them.  Trachea,  every  where  of  a  bright  red  ;  its  mucous 
membrane  was  entirely  destroyed  over  its  fleshy  portion,  with 
numerous  small,  rounded,  superficial  ulcerations,  from  one  to 
two  lines  in  diameter,  in  the  rest  of  its  extent  ;  these  existed 
also  in  the  bronchia,  being  situated  between  the  rings.  The 
submucous  tissue  corresponding  to  the  large  ulceration  in  the 
trachea  Vv'as  generally  thickened  ;  in  some  points  it  was  de- 
stroyed, which  caused  the  part  to  be  very  uneven.  Bronchial 
glands,  large  and  greyish,  with  some  tuberculous  deposit; 
cervical  glands,  healthy. 

Thorax.  —  Percussion  of  the  left  side,  very  clear  anteri- 
orly ;  the  cavity  was  partly  occupied  by  the  lung  (which  ad- 
hered by  its  summit  for  about  three  inches),  and  by  a  quart  of 
dirty-colored  serum,  containing  numerous  yellow  albuminous 
fragments.  A  very  soft  false  membrane  invested  the  lower 
lobe,  at  the  upper  part  of  which  was  an  opening  of  two  lines 
in  diameter,  communicating  with  an  excavation,  about  the 
size  of  a  nut,  lined  by  the  remains  of  tuberculous  matter,  with- 
out any  false  membrane,  and  communicating  with  the  bronchia. 
This  lobe  contained  numerous  grey,  semi-transparent  granula- 
tions ;  the  summit  of  the   upper  lobe   was   indurated,  with  a 


Chap.  9.]  ACUTE  pain;  dtspnœa,  he.  401 

large  quantity  of  grey  and  blackish  matter,  in  the  centre  of 
which  there  was  a  tubercle  about  the  size  of  a  common  nut  ; 
elsewhere  there  was  very  little  greyish  matter,  but  some  irreg- 
ularly dispersed  tubercles.  The  right  lung  adhered  to  the  cos- 
tal  pleura  by  means  of  a  firm  false  membrane  two  lines  thick 
inferiorly  ;  the  upper  lobe  was  almost  entirely  converted  into 
a  grey,  shining,  elastic  substance,  surrounding  numerous  dull 
white  granulations  ;  it  presented  at  its  summit  two  excava- 
tions, about  the  size  of  a  nut,  filled  with  a  turbid,  reddish 
fluid  and  scattered  tuberculous  fragments,  but  no  false  mem- 
brane ;  the  inferior  lobe  contained  a  similar  cavity,  with  some 
grey  granulations  and  engorged  portions.  Heart,  healthy  j 
some  irregularly  distributed  redness  in  the  aorta. 

Abdomen.  —  The  gastric  lining  membrane  presented  a 
pink  tint  in  the  great  cul-de-sac,  where  it  was  extremely  soft- 
ened in  some  spots  ;  it  was  perfectly  healthy  near  the  py- 
lorus, rather  softened  elsewhere,  and  partially  ulcerated  in 
some  points  of  its  lower  half.  In  the  middle  third  of  the 
small  intestine  there  were  numerous  transversal  ulcerations, 
three  of  which  encircled  the  gut  ;  lower  down  the  elliptical 
patches  were  nearly  all  ulcerated,"^  with  destruction  of  the 
corresponding  raucous  membrane  ;  the  submucous  tissue  was 
rough,  thickened,  presenting  numerous  small  excavations  in 
the  same  points  ;  elsewhere  the  mucous  membrane  was  healthy. 
In  the  ascending  colon  there  was  one  large  ulceration,  with 
numerous  smaller  ones  in  the  rectum  and  caecum,  and  in  its 
appendix.  The  lining  membrane  was  softened  in  the  lower 
half  of  the  large  intestine  ;  the  other  abdominal  viscera  were 
healthy. 

430.  U  we  now  glance  over  the  preceding  observations,  we 
c  3 


402  SYMPTOMS.  — •  PERFORATION  OF  THE  LUNG  ;    [Part  II, 

find  that  at  a  variably  advanced  period  of  phthisis,  the  patients 
experienced,  sudclenJy,  m  one  side  of  the  chest,  a  violent  pain 
usually  with  extreme  dyspnœa  and  intense  anxiety,  which 
were  succeeded  by  all  the  general  symptoms  of  acute  pleurisy  ; 
that  these  symptoms  persisted  unabated  or  with  slight  remis- 
sions to  the  last,  death  following  their  appearance  in  twenty- 
four  hours  to  thirty-eight  days  (Obs.  38,  40)  ;  that  after  death 
there  was  found  a  variable  quantity  of  air,  pus,  or  bloody-col- 
ored fluid  in  the  side  of  the  chest  where  the  pain  had  been 
felt,  and  also  a  perforation  of  the  lung  from  the  opening  of  a 
tuberculous  excavation  into  the  pleural  cavity. 

431.  The  connexion  of  the  symptoms  with  the  state  of  the 
kings  after  death  is  so  striking,  that  the  simple  exposition  of 
the  facts  is  sufficient  to  show  their  mutual  dépendance.  The 
pain  is  caused  by  the  passage  of  the  tuberculous  matter  into 
the  pleurae,  while  the  dyspnoea  and  anxiety  are  the  effects  of 
the  more  or  less  rapid  effusion  at  first  of  air,  and  afterwards 
of  a  variably  composed  fluid  -,  so  that  whenever,  in  case  of 
phthisis,  a  violent  pain  in  one  side  of  the  chest  shall  come  on 
suddenly,  accompanied  with  dyspnoea,  anxiety,  and  all  the 
general  symptoms  of  acute  pleurisy,  we  may  conclude  that 
perforation  of  the  lung  has  taken  place  in  the  manner  we  have 
described.  At  least,  it  was  by  these  symptoms  that  we  diag- 
nosticated with  M.  Chomel  the  accident  in  question,  in  the 
examples  we  have  just  detailed. 

432.  These  symptoms  are  besides  so  rational,  that  we  might 
almost  have  anticipated  their  presence  à  priori;  and  from  the 
analogy  existing  between  the  perforation  of  the  small  intestine 
and  that  of  the  lungs,  they  might  still  more  easily  have  been 
foreseen.  There  is,  in  fact,  in  both  cases  at  the  instant  of  per- 
foration, an  effusion  of  irritating  fluid  on  a  serous  membrane  ; 
and,  as  sudden  pain  with  all  the  symptoms  of  intense  inflam- 


Chap.  9.]  SUDDEN    DYSPNŒA    AND    ANXIETY.  403 

mation  occurs  in  one  case,  we  might  naturally  expect  to  find 
them  in  the  other.  But  if  this  sudden  pain  in  a  certain  part 
of  the  abdomen,  accompanied  by  the  symptoms  of  intense 
peritonitis,  is  sufficient  for  the  diagnosis  of  perforation  of  the 
intestine,  it  is  natural  to  suppose  that  the  case  would  be  the 
same  in  perforation  of  the  lung,  and  that  a  pain  equally  sud- 
den and  severe  in  one  of  the  sides  of  thechest,  connected  with 
extreme  dyspnoea  and  with  the  other  symptoms  of  pleurisy, 
would  be  sufficient,  especially  in  a  phthisical  patient,  to  prove 
its  existence. 

433.  Sudden  dyspnœa  and  anxiety,  independently  of  pain, 
may  also  lead  us  to  suspect  the  presence  of  perforation.  Of 
this  the  following  observation  is  a  proof. 


FORTY-FOURTH    OBSERVATION. 

A  WOMAN,  œt.  24,  of  a  rather  delicate  constitution,  was  ad- 
mitted into  the  hospital  of  La  Charité,  September  28th, 
1824.  She  was  subject  to  shortness  of  breath  from  her  in- 
fancy, was  little  liable  to  colds,  and  then  only  for  a  few  days  ; 
had  never  had  pneumonia,  and  had  now  been  ill  three  months 
and  a  half  Without  any  appreciable  cause,  she  was  attacked 
at  first  with  cough  and  white  expectoration,  which  gradually  be- 
came opaque  and  greenish  ;  rigors,  at  first  frequent  and  irregular, 
afterwards  rarer  j  there  had  been  increase  of  her  habitual  dys- 
pnœa, night  perspirations,  and,  since  the  third  month,  increas- 
ed heat  in  the  evening  ;  appetite,  a  little  diminished  ;  vomiting 
often  occasioned  by  cough  ;  from  the  first,  emaciation  was  evi- 
dent ;  no  diarrhoea. 

September  29th.  Face,  rather  pale  ;  considerable  debility  ; 


404  SYMPTOMS.  PERFORATION  OF  THE  LUNG  ;     [Part  II, 

moderate  emaciation  ;  sleep,  often  interrupted  ;  pain  in  the  left 
shoulder  from  the  commencement,  worse  during  the  night  than 
during  the  day,  that  is,  when  the  accesses  of  cough  were  the 
most  severe  ;  sputa,  greenish,  opaque,  not  striated,  surrounded 
by  a  very  frothy  mucus  ;  percussion,  nowhere  very  clear  ;  reso- 
nance of  the  voice  and  tracheal  respiration  under  the  left  clav- 
icle; pulse,  rather  quick  ;  tongue,  whitish,  and  had  not  a  very 
thick  coat  ;  bitter  taste  in  the  mouth  ;  appetite,  pretty  good  ; 
digestion,  easy  ;  abdomen,  yielding,  without  pain  ;  occasional 
colic  the  last  six  weeks  ;  dejections,  infrequent.) 

(Decoction  of  Iceland  moss  ;  gum  potion  ;  two  cups  of 
milk  ;  a  quarter  of  the  house  allowance.) 

From  this  period  until  death,  which  took  place  on  the  1st 
of  January,  the  cough  was  always  very  troublesome,  espe- 
cially during  the  night,  when  the  patient  was  sometimes 
oblio-ed  to  retain  the  sitting  posture  to  relieve  the  dyspnoea. 
The  pains  in  the  shoulder  did  not  increase  ;  from  Nov.  25th 
to  the  28th  they  were  very  acute  in  the  left  side,  without  any 
increase  of  the  dyspnoea.  At  this  period,  percussion  was 
clear  under  the  left  clavicle,  and  we  heard  indistinct  pectoril- 
oquy both  here  and  in  the  corresponding  point  posteriorly  ; 
lower  down  the  respiration  was  coarse,  mingled  with  a  large, 
dry,  crepitating  râle.  December  24th.  Distinct  pectoriloquy 
and  a  gurgling  were  heard  where  the  crepitation  had  existed 
previously  ;  difficulty  of  breathing  as  before  ;  decubitus  hori- 
zontal. 26th.  The  dyspnoea  became,  suddenly,  very  intense, 
without  having  been  preceded  or  followed  by  pain  in  the 
chest.  On  the  morning  of  the  2Tth,  it  was  still  urgent  ;  the 
decubitus  was  elevated  ;  the  heat  considerable  ;  pulse,  rapid; 
face,  injected  ;  expression,  animated  ;  speech,  hurried  ;  great 
anxiety;  percussion  of  leftside  infinitely  clearer  than  the  right  ; 
the  respiration  in  this  part  was  confused  and  distant,  and  after 


Chap.   9.]  SUDDEN    DYSPNŒA    AND    ANXIETY.  405 

every  respiratory  movement  there  was  a  sound  similar  to  what 
we  produce  by  blowing  into  an  empty  bottle.  The  abstraction 
of  five  ounces  of  blood  produced  only  a  momentary  relief.  The 
next  day  the  dyspnœa  and  anxiety  were  increased  ;  she  said 
she  should  die  of  suffocation  ;  no  change  in  auscultation  or 
percussion  during  the  following  days,  and  the  patient  expired 
during  the  night  of  the  Slst,  after  experiencing  every  grada- 
tion of  suffocation,  but  without  pain  in  the  left  side  of  the 
chest.  The  sputa  assumed  rapidly  the  nummulated  form, 
were  without  smell,  although  after  the  26th  of  December,  the 
patient's  breath  was  very  faetid.  It  had  an  odor  similar 
to  that  which  arises  from  animal  matter  which  has  been 
macerated  for  some  time.  From  the  commencement  of 
the  extreme  dyspnœa  the  heat  had  continued  elevated, 
rigors  rare,  night  perspiration  variable.  The  appetite  gradu- 
ally diminished,  and  from  the  1st  of  December  entirely  dis- 
appeared ;  the  vomiting,  which  consisted  of  food  and  mucus, 
yielded  about  the  middle  of  November,  after  the  use  of  Seltzer 
water.  For  some  days  the  epigastrium  was  slightly  painful  ; 
the  thirst  was  never  urgent.  Diarrhœa  came  on  in  October  ; 
during  the  first  twenty  days  it  was  scanty  and  intermittent, 
afterwards  constant  and  copious  ;  faeces,  yellow,  soft,  without 
blood  or  mucus.  The  patient's  spirits  were  pretty  good  to  the 
last  ;  she  dreaded  death,  and  constantly  referred  to  the  sub- 
ject. She  always  took  the  julep  in  the  evening,  with  a  grain 
of  opium  in  the  gum  potion  during  the  day;  her  drink  con- 
sisted of  rice  water  and  the  white  decoction  with  canella  ;  the 
food  was  diminished  with  occurrence  of  the  diarrhoea  and 
decreased  appetite. 

Opening  of  the  corpse  thirty-tivo  hours  after  death. 
Exterior.  —  Considerable  emaciation. 


406  SYMPTOMS. PERFORATION  OF  THE  LUNG  ;    [PaVt  II, 

Head.  —  Some  miliary  aracbnoidean  granulations  in  groups, 
adherent  to  the  dura  mater  ;  brain,  very  firm  ;  cortical  sub- 
stance extremely  pale  ;  two  small  spoonfuls  of  fluid  in  each 
latéral  ventricle,  rather  less  in  the  inferior  occipital  fossae  ;  en- 
cephalon,  otherwise  healthy. 

Neck.  —  Larynx  and  epiglottis,  natural  ;  trachea,  of  rather 
a  deep  red,  with  two  small  ulcerations. 

Thorax.  —  Left  lung,  adherent  over  its  upper  three  fifths 
by  means  of  a  very  dense  false  membrane  ;  it  was  elsewhere 
free,  and  invested  with  a  reddish  soft  membrane,  prolonged 
over  the  diaphragm  and  ribs,  from  which  it  was  separated  by 
a  space  which  was  partly  occupied  by  a  reddish,  turbid  fluid, 
which  was  similar,  except  in  density,  to  what  we  find  in  tuber- 
cular excavations.  Immediately  below  the  adhesions  there 
was  an  opening  of  five  lines  in  diameter  in  the  lower  lobe, 
communicating  with  a  cavity  which  extended  upwards  into 
the  interlobular  fissure.  The  excavation  was  lined  by  yellow- 
ish tuberculous  fragments,  traversed  by  numerous  bands  of 
about  a  line  thick,  composed  of  a  very  dark,  greyish,  semi- 
transparent  substance,  in  which  no  vascular  ramifications  could 
be  traced  :  several  small  excavations  communicated  with  the 
one  described  ;  a  very  small  portion  of  the  lobe  was  permea- 
ble to  tJie  air  ;  at  the  summit  of  the  upper  lobe  there  was  a 
similar  and  still  larger  excavation  ;  the  remainder  of  the  lobe 
presented  numerous  small  cavities  communicating  together, 
with  a  blackish-grey  substance  in  their  intervals,  so  that  it  was 
nearly  wholly  incapable  of  respiration.  The  right  lung  offer- 
ed inferiorly  some  adhesions,  and  in  its  upper  lobe  numerous 
softened  tuberculous  masses,  the  largest  of  which  were  in  the 
centre  ;  these  were  less  numerous  in  the  lower  lobe,  which 
was  engorged  in  many  points,  and  firm  without  hepatization 
in  the  remainder  of  its  extent.     The  bronchia  were  rather  red 


Chap.  9.]  METALLIC    TINKLING,    &1C.  407 

on  both  lungs,  aud  extensively  communicated  with  the  exca- 
vations ;  the  bronchial  glands  were  greyish,  voluminous,  not 
tuberculated.     Heart,  rather  small  ;  aorta,  healthy. 

Abdomen.  —  A  quart  of  clear  fluid  in  the  peritoneal  cavity. 
The  stomach  contained  much  viscid  inucus  ;  and  in  the  centre 
of  the  great  cul-de-sac,  for  as  large  a  space  as  the  palm  of  the 
hand,  the  submucous  vessels  were  much  distended,  and  the 
lining  membrane  soft  as  mucus  over  one  half  of  this  surface  ; 
it  was  elsewhere  healthy.  The  elliptical  patches  in  the  lower 
fifth  of  the  sm.all  intestine  were  thicker  than  natural,  nearly 
all  more  or  less  ulcerated  ;  these  ulcers  were  somewhat  rough, 
owinff  to  the  thickeninc;  and  ulcerations  of  the  submucous  tis- 
sue  ;  in  the  intervals  there  were  numerous  yellowish  granula- 
tions, many  of  which  were  ulcerated  ;  the  mucous  membrane 
in  the  other  portions  was  healthy.  Some  small  ulcerations  in 
the  caecum  ;  lining  membrane  of  the  large  intestine,  pale, 
every  where  thicker  than  natural  ;  rather  softened  in  the 
ascending  colon,  and  elsewhere  not  firmer  than  mucus  ;  sub- 
mucous layer,  white,  opaque,  and  three  times  as  thick  as  usual 
in  the  same  parts.  Mesenteric  glands,  red  and  voluminous, 
not  tuberculated  ;  the  mesocolic,  small  and  healthy  ;  liver, 
fatty  ;  bile  in  the  gall-hladder,  natural  ;  spleen,  twice  its  usual 
volume  ;  the  other  viscera  were  healthy. 

434.  Notwithstanding  the  absence  of  pain,  we  did  not  hesi- 
tate about  the  existence  of  perforation  of  the  lungs,  when 
the  patient  told  us  of  the  sudden  invasion  of  the  dyspnœa  and 
anxiety.  However,  the  diagnosis  here,  as  in  the  preceding 
cases,  was  assisted  and  comfirmed  by  auscultation  and  percus- 
sion ;  for  on  percussion  of  the  suffering  side  shortly  after  the 
commencement  of  the  oppression,  pain  [was  there  any  pain  ?] 
and  anxiety,  there   was  a   very  clear  sound  produced,   as  we 


408  SYMPTOMS.  — --  PERFORATION  OF  THE  LUNG  ;    [Part  II) 

already  know,  and  this  sound  was  clearer  than  that  produced 
by  percussion  of  the  opposite  side.  The  ear,  when  applied  to 
the  most  sonorous  part,  was  unable  to  detect  any  respiration, 
or  at  least  it  was  heard  as  if  from  a  distance,  for  a  short  time 
only,  very  seldom,  and  in  a  very  confused  manner.  This 
twofold  phenomenon  indicates,  as  Laennec  has  stated,  the  pres- 
ence of  a  certain  quantity  of  air  between  the  costal  pleura  and 
the  lungs,  and  as  pneumo-thoraxis  one  of  the  immediate  effects 
of  perforation  of  the  latter,  we  must  necessarily  be  induced  to 
believe  that  the  pneumo-thorax  was  the  result  of  it  in  the  pres- 
ent case.  But  one  readily  conceives  that  in  the  absence  of 
the  symptoms  we  have  mentioned,  the  pneumo-thorax  would 
have  been  much  less  valuable  relative  to  the  point  we  are  ex- 
amining, since  it  may  arise  froin  other  causes  than  perforation 
of  the  lungs. 

435.  Sooner  or  later  a  certain  quantity  of  pus  or  purulent 
fluid  was  conjoined  to  the  presence  of  a  gas,  and  when  this 
was  the  case  the  metallic  tinkling  was  produced  by  the  inspi- 
ration, expiration,  or  speaking.  This,  however,  depended  on 
the  communication  of  the  pleural  cavity  with  the  bronchia 
(as  in  Obs.  38, 40,  &,c.)  ;  in  those  cases  auscultation  in  show- 
ing that  metallic  tinkling  exists,  and  percussion  announcing  the 
presence  of  a  certain  quantity  of  air  in  the  cavity  of  the  pleura 
proved,  independently  of  other  symptoms,  that  perforation  had 
existed.  But,  as  the  reader  may  have  observed,  this  combina- 
tion of  circumstances  does  not  always  take  place  (Obs.  39),  for 
sometimes  tuberculous  cavities,  when  opened  into  the  pleura, 
do  not  communicate  with  the  bronchia,  and  then  there  is  no 
metallic  tinkling.  This  may  also  be  the  case  when  the  effusion 
of  air  is  not  accompanied  by  a  fluid,  or  when  the  latter  is  too 
scanty.  Auscultation  cannot,  therefore,  detect  perforation  in 
any  case  until  some  time  after  its   occurrence  ;  and  in  those 


Chap.  9.]  METALLIC    TïNIILING,    StC.  409 

instances  where  no  con:intiunication  with  the  pleural  cavity  ex- 
ists, the  diagnosis  depends  entirely  on  the  other  symptoms. 

436.  The  quantity  of  fluid  necessary  for  the  production  of 
the  metallic  tinkling,  does  not  seem  to  he  very  considerable, 
since  we  have  heard  it  (Obs.  41),  when  percussion  detected 
no  dulness  of  sound.  On  the  other  hand,  a  large  accumu- 
lation of  fluid  did  not  appear  to  interfere  with  its  presence 
(Obs.  3S). 

437.  The  seven  preceding  observations,  including  another 
which  we  have  thought  it  unnecessary  to  detail,  are  the  only 
examples  we  have  met  with  ;  and  in  all,  the  rational  symp- 
toms, independently  of  auscultation  and  percussion,  were  suffi- 
cient for  the  diagnosis  of  the  lesion.  This  seems,  however, 
not  to  be  always  the  case  ;  for  in  the  three  examples  related 
by  Laennec,  in  his  important  work  on  auscultation  (Obs.  31, 
39,  41),  these  symptoms  do  not  appear  to  have  been  present. 
When  this  is  the  case,  nothing  would  lead  us  to  detect  its  ex- 
istence, and  if  the  discovery  were  made  it  would  be  by  acci- 
dent, as  it  were,  by  auscultation  and  percussion,  and  this  could 
happen  only  when  there  is  a  communication  existing  with  the 
bronchia,  for  then  alone  is  there  metallic  tinkling. 

438.  Percussion  and  auscultation  would  also  be  the  only 
means  of  diagnosis  we  should  have  of  perforation  of  the  lung, 
if  the  symptoms  were  but  slightly  marked,  since  they  would 
indicate  a  pneurao-thorax,  of  which  perforation  of  the  lung 
is  incomparably  the  most  frequent  cause. 

439.  There  were  some  variations  in  the  pain  important  to  be 
noticed.  Acute,  inobservations  thirty-eight,  thirty-nine,  forty, 
and  forty-two,  it  was  much  less  urgent  in  the  others,  though 
from  its  suddenness,  the  accompanying  dyspnoea,  or  the  mod- 
ification in  the  physical  condition  of  the  chest,  it  did  not  cease 

D  3 


410  SYMPTOMS. PERFORATION  OF  THE  LUNO  ;    [Part  II, 

to  be  important  for  the  diagnosis.  We  have,  in  fact,  seen  in 
observation  forty-one,  that  at  the  moment  the  pain  came  on, 
and  a  short  time  before,  the  patient  thought  she  perceived  the 
circulation  of  a  gas  in  the  left  side  of  the  chest  ;  a  sensation 
which  continued  some  time,  and  which  was  doubtless  produced 
by  the  passage  of  the  air  into  the  corresponding  cavity.  In- 
stead of  being  surprised  at  the  slight  variations  in  the  pain,  we 
ought  rather  to  wonder  they  were  not  more  considerable  ;  it 
was  equally  acute  in  observations  thirty-nine  and  forty-two,  as  in 
the  others,  and  in  both  these  instances  it  was  caused  by  the 
passage  of  the  contents  of  a  very  small  excavation  into  the 
pleural  cavity,  which  did  not  communicate  with  the  bronchia, 
whilst  in  the  others  the  excavation  was  considerable,  and  com- 
municated with  the  bronchia.  Lastly,  the  pain  was  absent  in 
one  case  (Obs.  44),  in  which  the  perforation  was  large,  the 
cavity  extensive,  and  the  quantity  of  the  effused  irritating 
matter  doubtless  very  great. 

440.  The  dyspnœa  and  anxiety,  except  in  observation 
forty-one,  were  very  urgent,  and  in  this  exceptional  case,  the 
slightest  movement  produced  a  tendency  to  syncope.  This 
example  was  also  interesting,  an  account  of  the  decubitus  on 
the  right  side  with  the  head  low,  while  the  majority  of  the 
other'patients  retained  the  sitting  posture. 

441.  It  is  also  worth  observing,  that  notwithstanding  so 
great  and  sudden  an  obstacle  to  the  circulation,  the  face  was 
generally  of  its  natural  paleness  ;  a  fact,  however,  which  must 
not  be  regarded  as  extraordinary,  since  we  frequently  observe 
patients  exceedingly  pale  when  the  dyspnœa  is  extreme  ;  as 
for  instance,  in  great  dilatation  of  the  heart,  and  even  in  some 
cases  where  the  right  and  left  cavities  communicate. 

442.  The  time  elaj)sing  from  the  moment  of  perforation  to 
the  fatal  termination,  must  also  be  noticed.     Death,  in  fact 


Chap.  9.]  PLACE  PERFORATED.  411 

took  place  in  sixteen,  twenty-four,  thirty-six,  and  seventy-two 
hours,  six,  twenty,  and  thirty-six  days,  from  the  origin  of  the 
first  symptoms  ;  the  cause  of  these  differences  it  is  not  easy  to 
explain.  We  may  in  vain  seek  it  in  the  relative  strength  of 
the  patients  ;  for  the  female  who  was  the  subject  of  obser- 
vation thirty-nine,  and  who  died  after  seventy-two  hours,  was 
apparently  as  strong  as  the  patient  of  the  thirty-eighth  obser- 
vation, who  survived  thirty-six  days.  We  cannot  refer  it 
either  to  the  difference  in  treatment,  the  latter  having  remain- 
ed during  the  three  days  following  the  perforation,  in  his  own 
house,  suffering  acute  pain,  without  any  remedies  being  ap- 
plied. The  variations  in  the  size  of  the  excavations,  or  the 
quantity  of  the  fluid  which  escaped  into  the  pleural  cavity, 
also  fail  to  afford  any  assistance  in  the  inquiry,  but  rather  in- 
crease our  difficulty,  for  where  patients  died  from  thirty-six  to 
seventy-two  hours  after  the  accident,  the  cavity  was  very  small, 
not  communicating  with  the  bronchia,  and  necessarily  dis- 
charging only  a  small  quantity  of  matter  into  the  pleura.  We 
insist  on  these  details,  because  it  is  important  that  the  phy- 
sician should  be  aware,  that  in  certain  complications,  mortal  in 
their  nature,  the  fatal  termination  may  take  place  some  hours 
or  some  weeks  after  their  invasion,  without  his  being  able  to 
anticipate  or  explain  these  differences. 

443.  In  five  of  our  cases  the  perforation  occurred  at  the 
same  point,  viz.,  opposite  the  angle  of  the  third  or  fourth  ribs. 
This  fact  is  interesting,  both  from  its  correspondence  with  the 
seat  of  the  pain  in  the  commencement,  and  because  it  is  doubt- 
less dependant  upon  the  progressive  development  of  tuber- 
cles from  above  downwards.  We  must  also  recollect  that  out 
of  the  eight  cases,  seven  were  on  the  left  side,  where  we  have 
already  seen  that  the  tuberculous  affection  was  rather  more  fre- 
quent and  farther  advanced  than  on  the  right.     We  have  only 


412  SYJiîPTOMS. PERFORATION  OF  THE  LUNG  ;    [Part  II, 

found  a  single  perforation  in  the  same  lung  ;  but  in  many 
cases  (Obs.  41),  tbere  were  numerous  yellow  and  white  spots, 
corresponding  to  softened  tubercles  ;  these  were  only  sepa- 
rated from  the  pleura  by  an  extremely  thin  layer,  and  they 
seemed  on  the  point  of  opening  into  the  pleural  cavity.  If 
we  consider  the  frequency  of  this  disposition,  we  may  be  sur- 
prised that  perforation  is  not  more  common  ;  this  is  doubtless 
to  be  attributed  to  the  adhesions  which  almost  invariably  take 
place.  For  the  summit  of  the  lung,  where  the  sides  of  the 
excavations  are  often  solely  formed  by  the  false  semi-cartilagi- 
nous membrane,  this  is  evident;  occasionally  also  the  tuber- 
culous matter  is  immediately  in  contact  with  the  ribs,  and  in 
some  cases,  traverses  the  intercostal  muscles.  In  these  ex- 
amples had  there  been  no  adhesions,  it  would  have  escaped 
into  the  pleural  cavity. 

444.  We  must  also  notice  the  rapidity  with  which  the  effu- 
sion of  turbid  or  sanguineous  fluid  may  occasionally  be  formed. 
It  was  considerable  in  observation  forty,  where  death  took 
place  in  twenty-four  hours  after  the  perforation,  although  per- 
cussion during  the  first  twelve  hours  was  clear  over  the  whole 
side  of  the  chest.  In  this  case  then  the  effusion  took  place 
in  less  than  twelve  hours.  In  observation  forty-one,  in  which 
the  serous  effusion  did  not  occur,  at  least  in  any  considera- 
ble quantity,  until  a  long  time  after  the  perforation,  the  pro- 
gress was  equally  rapid.  These  facts  are,  however,  strictly 
in  accordance  with  what  we  observe  in  simple  pleurisy,  and 
more  especially  in  the  cure  of  hydrocele  by  injection,  when  a 
considerable  effusion  of  purulent  fluid  is  formed  in  the  tunica 
vaginalis  in  a  few  hours. 

445.  In  cases  where  death  occurred  twenty -four  hours 
after  the  perforation,  there  was  also  a  soft  false  membrane, 


Chap.  9.]       QUANTITY    OF    THS    EFFUSION,    &tC.  413 

probably  organized,    every    where    investing    the    lung    and 
pleura. 

446.  We  shall  pass  over  many  other  circumstances  in  these 
observations  calculated  to  arrest  our  attention,  only  remarking 
that  the  quantity  of  fluid  in  the  cerebral  ventricles,  as  in  the 
cases  of  sudden  death,  was  very  small  ;  that  notwithstanding 
the  sudden  obstacle  to  the  circulation,  prolonged  in  some  cases 
during  several  days,  the  mucous  membranes  were  not  redder 
than  where  the  circulation  was  much  less  impeded  ;  this  seems 
to  prove  that,  to  produce  congestion  of  the  mesenteric  vessels 
and  mucous  membrane,  the  impediment  to  the  circulation  must 
have  existed  a  long  time.  Lastly,  we  will  observe,  that  not- 
withstanding the  intelligence  and  the  sensibility  of  the  patient, 
who  was  the  subject  of  observation  forty-three,  and  the  numer- 
ous questions  relative  to  the  state  of  the  trachea,  we  detected 
no  symptom  calculated  to  make  us  suspect  the  presence  of  the 
immense  ulceration  discovered  after  death. 

447.  The  cases  detailed  in  this  chapter  are  relative  to  indi- 
viduals in  whom  phthisis  had  existed  from  six  to  sixteen 
months,  and  whose  ages  varied  from  twenty-four  to  forty -five 
years.  Additional  observations  will  determine  whether  per- 
foration of  the  lung  takes  place  in  very  chronic  cases,  and  in 
old  people  ;  for  as  yet  the  number  of  facts  is  much  too  incon- 
siderable to  justify  any  conclusions  on  the  subject. 


414  SYMPTOMS. —  SUDDEN  DEATHS  ;  [Part  II, 


CHAPTER    X. 

SUDDEN    DEATHS. 

448.  We  have  already  seen  how  many  causes,  foreign  to 
the  existence  of  tubercles  in  the  lungs,  accelerate  the  fatal 
termination  in  cases  of  phthisis  ;  but  there  are  instances 
where  death  occurs  still  more  suddenly  and  unexpectedly. 
Sometime  the  appearances  after  death  seem  to  offer  some 
explanation,  while  in  others  the  most  rigorous  inspection  of 
all  the  organs  is  not  attended  with  any  satisfactory  results. 
The  following  observations  are  proofs  of  both  these  asser- 
tions. 


ARTICLE    I. 

UNEXPECTED    DEATHS,    WHICH    MAY    BE    EXPLAINED    MORE    OR    LESS 
PLAUSIBLY  BY  THE  STATE  OF  THE  ORGANS  AFTER  DEATH. 


FORTY-FIFTH    OBSERVATION. 

449.  A  GOLDSMITH,  33t.  22,  short,  obliged  to  leave  a  mili- 
tary life  on  account  of  his  feeble  constitution,  four  years  ill,  was 
admitted  into  the  hospital  of  La  Charité,  April  10th,  1823. 
His  illness  had  commenced  with  a  slight  cough  and  expectora- 
tion ;  these  had  since  continued,  and  for  the  last  seven  months 
had  been  very  troublesome,  since  which  they  had  been  associa- 
ted with  dyspnœa,  daily  rigors  and  night  perspirations.     During 


Chap.    10.]    EXPLICABLE    BY    THE    STATE    OF     ORGANS.       415 

the  last  three  days  of  March  he  had  experienced  a  rather 
acute  pain  in  the  left  side  of  the  chest,  with  increased  dys- 
pnoea. For  the  last  year  his  appetite  had  diminished,  and 
there  had  been  frequent  uneasiness,  with  sense  of  oppression 
in  the  epigastrium  ;  his  strength  had  much  diminished  ;  no 
diarrhoea  nor  haemoptysis.  11th.  Face,  natural;  slight  ema- 
ciation ;  slight  epigastric  oppression.  Cough,  frequent  during 
the  night  ;  sputa,  greenish,  opaque,  ragged,  and  surrounded  by 
a  limpid  fluid.  Percussion,  very  obscure  at  the  superior  and 
external  portion  of  the  right  part  of  the  chest,  clear  every 
where  else;  respiratory  murmur  natural  on  the  left;  tracheal  un- 
der the  right  clavicle,  with  a  rather  fine  crepitation  towards  the 
centre  of  the  same  side,  both  anteriorly  and  posteriorly.  Pulse, 
regular,  not  frequent  ;  tongue,  moist,  villous  in  the  centre 
natural  on  the  edges  ;  very  little  appetite  ;  stools,  rare  ;  ab- 
domen, not  painful.  The  patient  complained  of  nothing  but 
slight  epigastric  uneasiness. 

(Decoction  of  Iceland  moss  ;  julep  ;  one  eighth  of  the 
house  allowance.) 

21st.  The  dulness  of  sound  in  the  right  side  occupied  a 
larger  space  ;  appetite,  improved  ;  the  patient  was  able  to 
take  a  quarter  of  the  house  allowance  without  oppression  at 
the  epigastrium  ;  stools,  regular  ;  no  perspirations. 

(Blister  to  the  right  side  of  the  chest.) 

On  the  following  days,  some  pain  in  the  throat  ;  no  appe- 
tite ;  increased  heat  ;  and  on  the  26th  we  remarked  a  slight 
eruption  of  red  spots,  not  elevated,  extending  over  the  whole 
body  ;  desquamation  in  some  points  ;  the  pain  of  the  throat 
had  ceased  for  two  days  ;  the  tonsils  and  pharynx  were  nat- 
ural ;  pulse,  fuller  and  quicker  than  usual,  with  some  increase 
of  dyspnœa  ;  the  anorexia  persisted,  and  the  cough  excited 
occasional  nausea.     27th.  No  trace  of  eruption  ;  pulse,  full, 


416        srMPTOMs.  —  SUDDEN  DEATHS  ;    [Part  II, 

one  hundred;  respiration,  accelerated.  The  patient  com- 
plained of  a  pain  near  the  edge  of  the  left  ribs,  which  he  had 
felt  three  days  ;  percussion  of  the  same  side  of  the  chest  was 
every  where  clear,  and  respiration  natural  ;  on  the  right  side 
no  change  since  the  last  report.  Expectoration,  as  before  ; 
tongue,  natural  ;  one  moderately  firm  stool.  The  next  day, 
28th,  the  breathing  not  appearing  more  affected  than  usual, 
we  did  not  examine  the  patient.  In  the  evening  he  was  sit- 
ting up  in  the  bed  at  the  time  supper  was  being  distributed, 
and  asked  for  food  ;  a  few  minutes  afterwards  he  expired 
without  any  struggling,  his  companions  having  perceived  he 
was  not  quite  so  well  as  usual  half  an  hour  only  previously. 

Opening  of  the  corpse  tioeniy  hours  after  death. 

Exterior.  —  Muscular  system  well  developed  ;  slight 
emaciation  ;  some  vibices,  in  the  extremities  chiefly. 

Head.  —  Numerous  lacerations  of  the  dura  mater,  giving 
passage  to  the  arachnoidean  granulations  ;  cerebral  veins,  dis- 
tended with  blood  ;  considerable  injection  of  the  brain  and 
cerebellum.  Three  small  spoonsful  of  serum  in  the  lateral 
ventricles. 

Neck.  —  Larynx,  natural.  For  an  inch  and  a  half  below 
the  cordae  vocales,  the  lining  membrane  of  the  trachea  was 
red  and  thickened  ;  below  this  it  was  healthy,  then  again  of  a 
bright  red,  two  inches  above  the  bifurcation  ;  this  redness  ex- 
tended into  the  bronchia,  especially  on  the  right  side. 

Thorax.  —  The  right  lung  was  adherent  to  the  costal 
pleura,  inferiorly  by  means  of  cellular  prolongations,  and  supe- 
riorly by  a  false  semi-cartilaginous  membrane,  from  one  to 
three  lines  thick,  and  which,  by  being  prolonged  over  the 
interlobular  pleura,  constituted  the  greater  proportion  of  the 
sides  of  a  vast  excavation,  occupying  the  summit  of  the  upper 


Chap.   10.]    EXPLICABLE    BY    THE    STATE    OF    ORGANS.         417 

lobe,  and  communicating  with  smaller  cavities.  The  struc- 
ture of  the  membrane  was  not  uniform  ;  one  part  was  of  a 
pearly  color,  like  cartilage  ;  another  was  yellowish,  like  the 
intervertebral  ligaments  ;  here  and  there  were  some  portions 
of  grey,  semi-transparent  matter.  The  lower  lobe  was  slightly 
engorged,  and  contained  numerous  grey  granulations.  The 
left  lung  was  every  where  adherent,  voluminous,  firmer  infe- 
riorly  than  superiorly,  where  there  were  some  half  emptied 
excavations,  and  grey,  semi-transparent  granulations.  In  the 
two  lower  thirds  its  tissue  was  of  a  bluish  grey  color,  and 
the  surface  formed  by  an  incision,  rather  granulated  ;  pressure 
forced  out  a  certain  quantity  of  greyish  turbid  fluid,  almost 
without  air.     Heart,  rather  voluminous,  but  healthy. 

Abdomen. — The  stomach  contained  a  moderate  quantity  of 
turbid  fluid  ;  its  mucous  membrane  presented  some  dark  look- 
ing stripes,  was  a  little  softened  in  the  great  cul-de-sac,  and 
healthy  in  the  remainder  of  its  extent  ;  duodenum,  natural  ; 
many  elliptical  patches  of  the  small  intestine,  red  and  more  or 
less  ulcerated  ;  the  large  intestine  contained  much  mucus, 
with  very  little  fœcal  matter,  and  presented  in  the  ascending 
colon  some  small  ulcerations,  with  tuberculous  granulations  in 
the  centre  of  the  greater  number  ;  the  mucous  membrane  was 
thickened  and  detached  around  their  edges,  but  every  where 
else  natural.  Many  of  the  mesenteric  glands  were  rather  red 
and  voluminous  ;  the  other  viscera  of  the  abdomen  were 
healthy. 

450.  The  right  lung  and  a  great  proportion  of  the  left  were 

incapable  of  respiration  ;  the  left  lung  was  hepatized,  and  the 

rapidity  with  which  this  had  taken  place  explains  the  patient's 

sudden  and  unforeseen  death.     Thirty -six  hours  before  death, 

E  3 


418        SYMPTOMS.  —  SUDDEN  DEATH  ;     [Part  11, 

the  left  side  was  every  where  clear  on  percussion,  and  the  res- 
piration seemed  natural  ;  so  that,  in  this  period  of  time,  the 
whole,  or  least  the  greater  part  of  this  lung,  had  passed  from 
a  state  of  health  to  the  second  degree  of  inflammation,  a  fact 
by  no  means  extraordinary,  since  we  have  observed  it  several 
times  under  other  circumstances.  It  may  be  conjectured, 
from  the  existence  of  the  pain  experienced  by  the  patient  four 
days  before  death,  that  there  was  then  some  nucleus  of  in- 
flammation in  the  substance  of  the  lung,  and  that  this  was  the 
case,  is  rather  probable  ;  but  this  supposition  does  not  inter- 
fere with  the  conclusion,  that  the  greater  part  of  the  hepatiza- 
tion had  taken  place  in  a  very  short  time  ;  perhaps  in  twenty- 
four  hours.  But  how  do  we  reconcile  the  existence  of  such 
feeble  symptoms  with  so  rapid  an  alteration  of  an  important 
organ  ?  How  explain  the  sudden  and  unforeseen  approach  of 
death  ?  We  confess  our  incompetency  to  give  any  satisfactory 
answer  to  these  questions. 

451.  Among  other  interesting  circumstances  attending  this 
observation,  we  must  mention  the  peculiar  and  compound 
nature  of  the  membrane  investing  the  summit  of  the  right 
lung,  and  the  almost  healthy  state  of  the  gastric  mucous  mem- 
brane, although  the  derangement  of  the  digestive  functions 
long  preceded  the  patient's  death. 


FORTY-SIXTH     OBSERVATION. 

452.  A  SERVANT,  aet.  32,  and  ill  sixteen  months,  entered 
La  Cliarité,  April  15th,  1822.  He  was  short,  diminutive, 
and  very  subject  to  colds  both  before  and  subsequently  to  a 
pleurisy,  which  attacked  him  at  the  age  of  twenty-five  years  ; 


Chap.   10.]    EXPLICABLE   BY    THE    STATE    OF    ORGANS.         419 

he  attributed  his  present  disease  to  repeated  exposure  to  cold 
in  a  journey  during  the  winter  of  1820  and  1821.  Since  that 
period  he  had  coughed,  and  was  Hable  to  some  dyspnoea  ;  ex- 
pectoration did  not  commence  until  seven  months  after  the 
cough  began,  at  the  end  of  which  period  the  emaciation  also 
commenced,  and  about  three  months  afterwards  night  perspira- 
tions came  on  and  had  continued  regularly  ;  finally,  during  the 
last  three  weeks  there  had  been  diarrhœa  and  sore  throat  ;  he 
hadnever  had  haemoptysis. 

April  16th.  Expression,  nearly  natural  ;  cough,  infrequent 
during  the  day,  troublesome  at  night  ;  expectoration,  greenish, 
opaque,  not  striated  ;  percussion  of  the  chest,  every  where 
clear  ;  considerable  resonance  of  the  voice  under  the  clavi- 
cles ;  indistinct  pectoriloquy  between  the  vertebral  column 
and  right  scapula  ;  voice,  husky,  nearly  as  it  had  been  the 
last  two  months  ;  no  pain  in  the  region  of  the  larynx  ;  pulse, 
frequent,  full  ;  heat,  moderate  ;  no  rigors  the  last  eight  days  ; 
anorexia;  throat,  painful;  free  edge  of  the  velum  and  pha- 
rynx, red  ;  deglutition,  easy  ;  no  pain  in  the  epigastrium  ;  four 
liquid  stools  the  last  twenty-four  hours. 

(Decoction  of  Iceland  moss  ;  gum  potion  ;  quarter  of  the 
house  allowance.) 

26th.  Aphonia,  sense  of  heat  and  prickings  in  the  larynx  ; 
velum  and  pharynx  as  before';  deglutition,  difficult  ;  three 
liquid  stools  ;  copious  perspiration. 

(Twelve  leeches  to  the  anus  ;  blister  to  the  neck  ;  infusion 
of  violets  with  gum  syrup  ;  gum  potion.) 

May  10th.  Aphonia  continues;  pains  in  the  larynx  less 
acute  ;  liquids  occasionally  returned  by  the  nose  ;  no  pain  in 
neck  ;  under  the  right  clavicle  and  in  the  corresponding  point 
posteriorly,  a  coarse  dry  râle,  and  whenever  the  patient  spoke 
the  air  seemed  to  enter  the  stethoscope  ;  some  of  the  sputa 


420        SYMPTOMS.  —  SUDDEN  DEATH  ;    [Part  11, 

were  rust-colored  ;  the  pulse  was  only  slightly  accelerated  ; 
heat,  moderate  ;  tongue,  natural  ;  very  little  appetite  ;  abdo- 
men, not  painful  ;  slight  diarrhoea. 

On  the  two  following  days  no  sensible  change  took  place, 
nor  was  there  any  on  the  13th  ;  on  the  same  day,  two  hours 
after  the  visit,  the  patient  was  found  dead.  A  gum  potion,  with 
syrup  of  poppies,  and  three  rice  creams  had  been  prescribed 
in  the  morning. 

Opening  of  the  corpse  twenty-three  hours  after  death. 

Exterior.  —  Nothing  remarkable. 

Head. — A  little  serous  fluid  in  the  upper  part  of  the 
arachnoid  ;  a  spoonful  in  each  lateral  ventricle  ;  slight  injec- 
tion of  the  cerebral  substance. 

Neck.  —  The  edges  of  the  glottis  were  infiltrated,  rather 
more  on  the  right  side  than  the  left,  in  the  latter  of  which 
they  were  a  line  and  a  half  thick  ;  the  lining  membrane  of  the 
larynx  was  pale  and  not  altered.  Immediately  below  the 
cordae  vocales,  were  two  ulcerations  of  three  lines  in  diameter  ; 
and  two  inches  above  the  bifurcation  of  the  trachea,  on  the 
fleshy  portion  there  was  another  ulceration  of  four  lines  wide, 
by  eight  in  length  ;  the  intervening  mucous  membrane  was 
healthy. 

Thorax.  —  Cellular  adhesions  over  the  whole  of  the  right 
lung  ;  a  very  large  excavation  at  its  summit,  lined  by  a  double 
false  membrane,  of  which  the  laiernal  layer  lay  either  on 
healthy  pulmonary  tissue,  or  on  white,  yellowish,  or  grey 
granulations,  which  were  numerous  in  the  remainder  of  the 
lung.  The  summit  of  the  left  lung  was  partially  adherent, 
and  contained  some  small  excavations.  In  the  remainder  of  its 
extent  there  were  three  zones  formed  of  grey,  semi-transparent 
matter,  about  an  inch  thick,  and  separated  by  layers  of  pul- 


Chap.  10.]  EXPLICABLE  BY  THE  STATE  OF  ORGANS.    421 

monary  tissue  of  nearly  the  same  dimensions,  and  slightly  en- 
gorged. This  grey  substance  was  interspersed  with  numerous 
whitish  or  yellowish  miliary  granulations.  Heart  and  aorta, 
healthy. 

Abdomen.  —  Lining  membrane  of  the  stomach  of  a  slight 
violet  color  in  the  great  cul-de-sac  ;  in  other  parts  healthy. 
That  of  the  small  intestine  presented  some  brownish-red  spots, 
and  in  the  lower  fifth  numerous  ulcerations,  generally  extend- 
ing to  the  muscular  layer.  The  mucous  membrane  of  the 
large  intestine  was  red  in  the  descending  colon,  with  three 
moderately  sized  ulcerations  in  the  right  and  transverse  colon. 
Liver,  rather  engorged  with  blood  ;  the  other  viscera  of  the 
abdomen  were  healthy. 

453.  If  we  glance  over  the  state  of  the  principal  viscera 
we  have  described,  we  see  in  the  brain  an  effusion  of  serum 
into  the  lateral  ventricles,  much  less  considerable  than  in 
many  cases  where  no  peculiar  circumstances  attended  death, 
so  that  it  cannot  here  be  considered  a  cause  of  the  fatal  ter- 
mination ;  the  state  of  the  lungs  did  not  prevent  their  continu- 
ing respiration  for  a  considerable  time.  We  may  make  the 
same  remark  as  to  the  abdominal  viscera,  so  that  nothing  in  the 
condition  of  these  organs  explains  the  cause  of  death.  The 
state  of  the  glottis  remains  to  be  examined.  It  will,  perhaps, 
be  thought  that  the  oedema  was  not  sufficient  to  produce  suffo- 
cation, and  in  proof  of  this  opinion  it  may  be  said  that  we  have 
not  mentioned  any  paroxysms  of  dyspnœa  which  characterize 
this  lesion.  To  this  we  will  reply  by  the  relation  of  a  fact 
which  we  observed  some  months  previously  ;  it  refers  to  a 
young  man  attacked  with  typhus  fever,  and  who  died  from 
violent  suffocation,  accompanied  with  a  wheezing  inspira- 
tion ;  these  symptoms  came  on  only  two  hours  before  death 


422  SYMPTOMS.  —  SUDDEN  DEATH  ;  [Part  II, 

and  we  afterwards  found  the  œdema  of  the  glottis,  and  of 
the  same  extent  as  in  the  case  before  us.  It  is  possible  then 
that  in  the  two  hours  elapsing  between  the  visit  and  the  pa- 
tient's death,  something  very  analogous  had  taken  place  in  the 
present  instance  ;  that  this  really  was  the  case,  cannot  how- 
ever be  ascertained. 

Not  insisting  longer  on  a  doubtful  supposition,  we  will  ob- 
serve that  we  have  collected  two  other  observations  of  œdema 
of  the  glottis  in  phthisical  patients,  less  marked  than  in  the 
present  case,  and  from  the  frequency  of  the  ulcerations  of  the 
epiglottis  and  larynx,  it  is  singular  that  our  examples  are  not 
more  numerous.  Œdema,  however,  is  not  usually  attendant  on 
ulcerations  in  the  intestines,  stomach,  &;c.  of  phthisical  patients, 
which  seems  to  indicate  that  the  cause  of  the  ulceration  is  entire- 
ly local,  and  that  it  does  not  influence  the  surrounding  tissues. 

The  deposition  of  the  grey  matter,  in  the  form  of  zones  in 
the  left  lung,  is  a  rare  anatomical  fact. 


ARTICLE     II. 

SUDDEN  DEATHS    WHICH     ARE    NOT   ACCOUNTED    FOR    BY    THE    POST- 
MORTEM APPEARANCES. 


FORTY-SEVENTH    OBSERVATION. 

454.  A  SEMPSTRESS,  ast.  23,  of  a  pretty  strong  constitu- 
tion, and  usually  enjoying  good  health,  not  liable  to  colds,  and 
having  never  been  seriously  ill,  entered  the  hospital  of  La 
Charité,  June,  23d,  1823.  She  had  coughed  uninterruptedly 
the  last  five  months  ;  and  during  the  first  two  had  not  expec- 
torated ;  dyspnoea  had  come  on  at  the  same  time  ;  there  had 


Chap.    10.]    INEXPLICABLE  BY  THE   STATE   OF  ORGANS.        423 

been  no  hfemoptysis,  pains  in  the  chest,  nor  rigors,  though 
from  the  first  she  had  been  very  sensible  to  cold  ;  and  for  the 
last  two  months  had  had  night  perspiration.  For  the  same 
period  her  appetite  had  been  much  diminished,  and  every 
thing  but  soup  caused  uneasiness  in  the  epigastrium  ;  there 
had  been  some  diarrhœa  and  rapid  emaciation.  24th.  Ex- 
pression, rather  lively  ;  inconsiderable  debility  ;  cough,  fre- 
quent at  night  ;  sputa,  greenish,  opaque,  ragged,  immersed  in 
saliva  and  clear  mucus  ;  some  dyspnœa  ;  dull  sound  on  per- 
cussion ;  gurgling  and  tracheal  respiration  under  the  left  clavi- 
cle ;  evident  pectoriloquy  in  the  corresponding  point  posteri- 
orly. Pulse,  rather  quick  ;  night  perspirations  ;  tongue, 
villous,  whitish  ;  bitter  taste  in  the  mouth  ;  very  little  appetite; 
abdomen,  yielding,  without  pain  ;  three  liquid  stools,  with 
scalding. 

July  3d.  Pectoriloquy  on  both  sides  between  the  shoul- 
ders ;  complexion,  florid  ;  expression,  animated  ;  pulse,  ac- 
celerated, small,  and  feeble  ;  perspirations  and  digestive 
functions  as  before.  5th.  The  patient  walked  in  the  garden, 
and  was  in  excellent  spirits.  The  next  day,  at  four,  p.  m., 
after  returning  to  her  bed  from  the  night  stool,  she  died  sud- 
denly, to  the  great  surprise  of  her  companions,  with  whom  she 
had  just  been  conversing. 

Opening  of  the  corpse  thirty-seven  hours  after  death. 

Exterior.  —  Considerable  emaciation,  with  numerous 
vibices  over  the  whole  surface. 

Head.  —  Very  slight  sub-arachnoidean  infiltration;  brain, 
rather  spotted  with  blood  ;  three  small  spoonsful  of  clear  serum 
in  the  lateral  ventricles,  and  an  equal  quantity  in  the  lower 
occipital  fossoe. 

Neck.  —  Larynx,  natural  ;  lower  part  of  the  trachea  of  a 


424  SYMPTOMS.  —  SUDDEN  DEATH  ;         [Part  II, 

bright  red  ;  numerous  tuberculated  cervical  glands  on  the  left 
side. 

Chest.  —  Cellular  adhesions  over  the  summit  of  the  lungs  ; 
some  excavations  in  the  same  regions,  rather  larger  on  the  left 
than  on  the  right  side,  lined  by  a  thick  and  firm  false  mem- 
brane, surrounded  by  grey,  semi-transparent  matter,  inter- 
spersed with  yellowish  tubercles,  forming  an  indurated  portion 
in  the  summit  of  each  lung,  about  two  inches  and  a  half  in 
height.  There  were  elsewhere  numerous  grey,  semi-trans- 
parent granulations.  The  bronchia  were  dilated  without  be- 
ing thickened  in  the  upper  half  of  the  left  lung;  the  lymphatic 
glands  around  their  principal  divisions,  and  the  trachea  were 
somewhat  tuberculated.  Heart,  rather  soft,  and  contained  no 
blood  ;  aorta,  every  where  red. 

Abdomen.  —  Stomach,  of  moderate  volume,  and  free  from 
bile  ;  mucous  membrane,  of  a  livid  color  about  the  cardia  and 
over  a  considerable  portion  of  the  great  cul-de-sac,  where  it  was 
also  a  little  softened  ;  elsewhere  it  was  healthy.  The  mucous 
membrane  of  that  part  of  the  small  intestine  which  rested  in 
the  pelvis  was  red,  butof  normal  consistence  and  thickness  with- 
out ulceration  ;  near  the  CEecum  some  crude  tuberculous  gran- 
ulations, about  the  size  of  hemp  seeds.  Jn  the  large  intestine 
the  lining  membrane  was  slightly  softened  and  tliickened,  with 
some  ulcerations  in  the  transverse  colon.  Liver,  red  and  a 
little  engorged  in  the  right  lobe  ;  bile  of  the  gall-bladder 
somewhat  viscous,  of  a  mahogany  color  ;  the  other  viscera  of 
the  abdomen  were  healthy. 

455.  The  affection  of  the  lungs  was  undoubtedly  consider- 
able ;  but  they  were  still  in  the  greater  part  of  their  extent 
capable  of  respiration,  and  some  minutes  before  death  the  res- 
piration went  on  regularly.     Between  this  moment  and  that 


Chap.   10.]    INEXPLICABLE  BY  THE  STATE  OF  ORGANS.        42 

in  which  death  suddenly  took  place,  no  appreciable  change 
occurred  in  the  organs.  They  cannot  then  explain  the  cause 
of  death.  Can  we  compare  the  viscera  to  the  muscles  of 
locomotion,  aud  think  that  in  certain  instances  they  suddenly 
become  incapable  of  continuing  their  functions  from  a  sense  of 
fatigue  ? 

456.  The  morbid  alterations  of  the  other  viscera  were  too 
inconsiderable  to  arrest  our  attention.  The  aorta  was  red,  but 
we  are  as  yet  ignorant  of  the  real  value  of  this  sign,  and  be- 
fore explaining  any  phenomenon  by  it,  we  must  learn  its  value. 


FORTY-EIGHTH     OBSERVATION. 

A  WOMAN,  aet.  60,  entered  the  hospital  of  La  Charité, 
July  14th,  1823,  of  a  strong  constitution,  usually  enjoying 
excellent  health,  seldom  subject  to  colds,  and  now  ill  the  last 
seven  months.  During  the  first  six  weeks  she  experienced 
general  uneasiness,  with  sense  of  weakness,  and  considerable 
diminution  of  appetite;  after  this  she  had  cough  with  expec- 
toration ;  during  the  three  last  months  dyspnœa,  pain  in  the 
right  side  of  the  chest,  and  universal  flushings,  which  much 
incommoded  her  ;  these  symptoms  continued,  with  some  slight 
improvement  in  the  appetite  ;  there  had  been  no  haemoptysis, 
diarrhœa,  colic  or  rigors.  15th.  Face,  pale,  thin  ;  considera- 
ble general  weakness  ;  sleep,  tranquil  ;  sense  of  oppression 
referred  to  the  epigastric  region  ;  little  cough  ;  sputa,  ragged, 
greenish,  opaque  ;  sound,  dull,  with  tracheal  respiration  and 
pectoriloquy  under  the  right  clavicle,  and  posteriorly  in  the 
corresponding  point;  doubtful  pectoriloquy  on  the  left  side; 
elsewhere  the  respiratory  murmur  was  rather  loud,  and  accom- 
F  3 


426  SYMPTOMS. — SUDDEN  DEATH;  [Part  II, 

panied  with  a  sonorous  râle  ;  occasional  pain  in  the  right  side  ; 
pulse;  rapid  ;  tongue,  clean  and  moist,  rather  red  ;  little  ap- 
petite ;  no  pain  in  any  part  of  the  abdomen,  except  we  em- 
ployed strong  pressure;  bowels,  regular:  some  ardor  urinae. 

(Decoction  of  Iceland  moss  ;  gum  potion  ;  a  quarter  of  the 
house  allowance  ;  a  cup  of  the  common  wine.) 

On  the  following  days  some  increase  of  the  appetite  ;  no 
rigors  nor  diarrhoea  ;  the  patient  spent  much  of  her  time  in 
walking.  25th.  She  did  not  appear  worse  than  usual;  she 
walked  out  during  the  day.  In  the  evening  the  face  became 
rather  hvid,  but  she  slept  tranquilly  ;  at  midnight  she  awoke, 
complained  of  suffocation,  and  at  one,  a.  m.,  was  found  dead. 
For  the  last  two  days  she  had  complained  of  nausea  and  dis- 
gust for  food. 

Opening  of  the  corpse  thirty  hours  after  death. 

Exterior. —  Slight  oedema  of  the  whole  of  the  right  lower 
extremity  ;  some  vibices  in  the  same  region  ;  crural  veins  pre- 
sented no  obstruction. 

Head. — The  dura  mater  was  ossified  for  about  a  square  inch 
in  surface,  near  the  posterior  portion  of  the  falx  ;  considerable 
infiltration  of  the  sub-arachnoidean  tissue  ;  the  choroid  plexus 
was  converted  into  vesicles  containing  a  serous  fluid,  of  which 
none  existed  in  the  cavity  of  the  ventricles  ;  cerebral  sub- 
stance, slightly  injected. 

Neck.  —  Larynx,  trachea  and  epiglottis,  natural. 

Thorax.  —  The  upper  half  of  the  right  lung  was  adherent 
to  the  costal  pleura  ;  a  large  excavation  communicating  with 
several  smaller  ones,  occupied  the  summit  ;  they  were  all  sur- 
rounded by  the  grey,  semi-transparent  substance  which  was 
interspersed  with  nuiDcrous  tubercles  ;  no  part  of  this  portion 
of  the  lung  was  healthy.     The  remainder  offered  numerous 


Chap.  10.]  INEXPLICABLE  BY  THE  STATE  OF  ORGANS.    427 

grey,  yellowish  granulations,  and  was  slightly  engorged.  Of 
the  left  lung  there  were  some  inconsiderable  adhesions,  with 
tuberculous  excavations  in  its  apex  ;  the  base  was  also  slightly 
engorged.  Heart,  small  and  healthy  ;  aorta,  large,  with  nu- 
merous yellow  patches  on  its  surface,  and  also  embedded  in 
its  parietes. 

Abdomen.  —  A  great  number  of  miliary,  semi-transparent 
granulations,  developed  in  a  very  thin,  cellular  false  membrane 
covering  the  small  intestine  and  mesentery.  Stomach,  rather 
contracted;  lining  membrane  red  and  softened  over  half  the 
great  cul-de-sac,  greyish  colored  and  healthy  elsewhere. 
Some  middle-sized  ulcerations  in  the  lower  five  feet  of  the  small 
intestine,  presenting  some  tuberculous  granulations  on  their 
surface,  with  here  and  there  denudation  of  the  muscular  coat  ; 
every  where  else  the  mucous  membrane  was  normal.  That 
of  the  large  intestine  was  softened  in  its  right  colon,  healthy 
in  the  rest  of  its  extent,  except  immediately  above  the  anus, 
where  there  were  three  small  ulcerations.  Mesenteric  glands, 
natural  ;  liver,  small,  red,  and  easily  broken  down  ;  twelve 
small  calculi  with  pointed  surfaces,  and  some  very  dark  bile 
in  the  gall-bladder.  Spleen,  much  softened,  of  usual  volume, 
easily  reduced  to  a  reticulated  texture  ,  kidneys,  red  ;  mucous 
membrane  of  the  bladder,'  injected.  A  small  fibrous  body, 
embedded  in  the  uterus,  which  was  of  a  pale  pink  color. 

457.  The  cause  of  the  sudden  death  is  not  more  appar- 
ent in  this  than  in  the  preceding  instance,  and  the  same  reflec- 
tions are  in  a  great  measure  applicable  to  both.  One  of 
the  lungs  was  still  permeable  to  air  throughout  its  greater 
part;  the  lesion  of  the  stomach  was  slight,  and  of  moderate 
extent  ;  the  ulcers  of  the  small  intestine  were  slight  ;  the 
mucous  membrane  of  the  colon  had  only  a  limited  softening. 


428    SYMPTOMS. SUDDEN  DEATH   INEXPLICABLE  ;    [Part  II, 

The  morbid  alterations  \^ere,  in  fact,  much  less  extensive  than 
in  many  cases  when  the  approach  of  death  was  slow,  and  pre- 
ceded by  a  long  struggle.  We  di  not  speak  of  the  slight  con- 
gestion of  the  lungs,  the  kidneys,  liver,  intestine,  and  of  the 
mucous  membrane  of  the  bladder  ;  for  these  lesions  were  pro- 
bably the  effect  and  not  the  cause  of  the  kind  of  death  of 
which  we  are  now  speaking,  and  may  to  a  certain  extent  be 
compared  to  the  vibices  found  on  the  skin.  We  shall  not, 
moreover,  stop  to  mention  farther  the  redness  and  slight  de- 
gree of  softening  of  a  part  of  the  mucous  membrane  of  the 
stomach,  which  is  probably  a  recent  lesion,  and  which  corres- 
ponded perhaps  to  the  disgust  for  food  experienced  by  the 
patient  two  days  before  death,  and  which  was  too  slight  in 
degree  to  be  of  much  importance  in  the  explanation  of  the 
death  of  the  patient. 

458.  We  have,  in  a  former  part  of  this  work  (Obs.  7), 
related  a  case  in  which  death  was  equally  sudden,  and  in 
which  all  the  viscera  were  extensively  modified.  In  this  case 
we  are  surprised  that  life  should  have  been  so  prolonged, 
and  that  death  should  have  taken  place  without  its  usual  pro- 
dromes. In  a  fourth  example,  similar  to  the  preceding,  and 
relating  to  a  woman,  aged  thirty-six,  the  progress  of  the  dis- 
ease was  rapid,  and  death  occurred  at  a  moment  when  the 
greater  portion  of  the  lungs  was  permeable  to  the  air,  the 
alterations  in  the  stomach  and  small  intestine  inconsiderable, 
the  brain  healthy,  and  the  emaciation  more  advanced  than 
in  the  cases  we  have  just  related.  It  is  remarkable,  in  fact, 
that  in  none  of  these  last  patients  was  the  emaciation  very  con- 
siderable. 

We  must  also  point  out  two  peculiarities,  comiàion  to  nearly 
all  the  observations  in  question,  and  not  present  in  cases  of 
phthisis  when  the  approach  of  death  has  been  gradual,  viz., 


Chap.    10.]  SOFTENING    OF    THE    BRAIN.  429 

the^ecchynioses  and  the  moderate  efFusion  of  fluid  into  the 
lateral  ventricles.  These  two  appearances  are  also  present  in 
other  instances  of  sudden  death,  when  it  occurs  during  conva- 
lescencej  or  under  other  circumstances,  without  any  important 
alteration  of  the  viscera  (203). 

459.  We  shall  terminate  our  remarks  on  cases  of  sudden 
death  by  relating  two  analogous  observations,  in  which  there 
was  a  remarkable  softening  of  the  whole  cerebral  substance. 


FORTY-NINTH     OBSERVATION. 

An  old-clothes-seller,  œt.  54,  of  a  lymphatic  and  sanguine- 
ous temperament,  subject  to  difficulty  of  breathing  from  his 
infancy,  and  to  cough  and  expectoration  the  last  two  years,' 
was  admitted  into  La  Charité,  April  9th,  I823.  From  the 
commencement  of  the  latter  period  he  had  experienced  pains 
between  the  shoulders,  also  in  the  epigastrium  and  under  the 
false  ribs;  with  these  jaundice  was  associated  eight  or  nine  times 
during  the  first  eleven  months  ;  it  had  not  since  reappeared, 
and  he  had  only  experienced  occasional  epigastric  pains,  and 
with  these  his  appetite  had  diminished.  He  also  stated  that 
anterior  to  the  cough  and  expectoration,  he  had  been  liable  for 
thirty  years  to  apoplectic  seizures,  characterised  by  sudden 
loss  of  strength  in  the  limbs,  flushings  of  the  face  and  vertigo, 
all  of  which  rapidly  disappeared.  He  had  never  lost  his  con- 
sciousness, and  these  attacks,  which  in  the  beginning  had  been 
rare,  had  gradually  become  more  frequent,  returning  every 
two  or  three  weeks,  and  followed  during  the  six  months  pre- 
ceding the  cough  by  weakness   and  numbness  in  one  or  the 


430    SYMPTOMS. SUDDEN  DEATH  INEXPLICABLE  ;    [Pai't  II, 

Other  side  of  the  body,  during  half  an  hour  or  an  houi-,  after 
which  they  entirely  disappeared.  10th.  Face,  pale  and 
thin  ;  no  headach  ;  no  pains  in  the  limbs  ;  speaks  rather 
hurriedly  ;  breathing,  accelerated  ;  cough,  rare  ;  sputa,  flat, 
green  and  opaque  ;  on  the  left  side  anteriorly,  percussion  was 
very  obscure  :  there  was  a  dry  râle  with  coarse  crepitation, 
but  no  pectoriloquy  ;  on  the  right  side,  respiration  seemed 
natural.  Pulse,  small  and  weak,  eighty-four;  rigors  for  the 
last  three  weeks,  returning  regularly  at  ten,  a.  m.,  followed 
by  heat  and  perspiration,  but  they  had  not  occurred  the  day 
before  his  entrance  into  the  hospital.  Tongue,  moist,  not 
red  ;  mouth,  rather  clammy  ;  scarcely  any  appetite  ;  no 
thirst  ;  abdomen,  not  painful  ;  no  diarrhœa. 

(Rice  water  ;  gum  syrup  ;  blister  to  the  left  side  of  the 
chest  ;  three  rice  creams  ;  two  soups.) 

In  the  following  days,  no  evident  change  either  in  the  state 
of  the  circulation  or  respiration  ;  some  heat  in  the  evenings, 
without  previous  rigors  or  consecutive  perspirations;  slight 
diarrhoea.  19th,  in  the  morning,  the  patient  experienced  an 
uneasiness  for  which  he  could  not  account  ;  the  following 
night  there  was  slight  delirium.  20th.  During  the  visit,  con- 
siderable stupor  ;  intellect,  nearly  gone  ;  pupils,  much  con- 
tracted ;  utterance,  embarrassed  ;  motions  of  both  sides  free  ; 
tongue,  moist,  not  deviated  ;  pulse,  one  hundred  and  thirty  ; 
respiration,  very  slow.  These  symptoms  persisted  until  ten, 
p.  M.,  when  he  expired. 

Opening  of  the  corpse  thirty-four  hours  after  death. 

Exterior.  —  Nothing  remarkable. 

Head.  — Several  lacerations  of  the  dura  mater  giving  pass- 
age to  granulations  springing  from  its  laminse.  Slight  infiltra- 
tion of  the  sub-arachnoidean  tissue  ;  brain,  pale,  moist,  and  of 


Chap.   10.]  SOFTENING    OF    THE    BRAIN.  431 

about  the  consistence  of  that  of  the  foetus  of  six  or  eight 
months  ;  there  was  a  spoonful  and  a  half  of  clear  fluid  in  each 
lateral  ventricle,  and  a  much  smaller  quantity  in  the  lower 
occipital  fossae.  The  tuber  annulare  and  the  cerebellum  were 
nearly  as  soft  as  the  cerebrum. 

Neck. — Larynx,  natural  ;  mucous  membrane  of  the  trachea, 
of  a  vivid  red  over  its  fleshy  portion. 

Chest.  —  Dense  adhesions  over  the  summit  of  the  right 
lung,  by  means  of  a  semi-cartilaginous  false  membrane,  from 
one  to  two  lines  thick.  A  vast  excavation  in  the  same  region 
surrounded  by  tubercles  and  the  grey,  semi-transparent  sub- 
stance, which  almost  entirely  occupied  the  remainder  of  the 
upper  lobe.  In  the  intervals  between  the  larger  masses  of 
grey  matter  there  was  a  homogeneous  firm  substance,  very 
much  resembling  the  jelly  from  veal,  and  presenting  in  de- 
tached points  a  slightly  granulated  appearance.  The  lower 
lobe  contained  a  few  tubercles  and  was  slightly  engorged. 
There  were  some  adhesions  over  the  summit  of  the  left  lung, 
the  upper  lobe  of  which,  except  that  it  did  not  contain  any  ex- 
cavations, was  rather  hard,  and  was  otherwise  affected  as  the 
right  was.  In  the  left  lung  the  bronchia  of  the  upper  lobe 
were  very  red  and  thickened  ;  they  were  thin  and  of  a  pink 
colorin  the  right  lung. 

Abdomen.  —  When  removing  the  anterior  parietes  of  the 
abdomen,  we  lacerated  the  gall-bladder,  which  was  closely  ad- 
hering to  them.  It  extended  an  inch  and  a  half  below  the  false 
ribs,  and  contained  two  hundred  calculi,  varying  in  size  from  a 
pea  to  that  of  a  millet  seed  ;  its  lining  membrane  was  destroy- 
ed over  an  inch  square  corresponding  to  the  adhesion,  as  also 
over  a  smaller  space  near  the  neck.  These  ulcerations  seem- 
ed as  if  produced  by  some  instrument.  The  mucous  mem- 
brane was  elsewhere  firm,  about  half  a  hne  thick,  and  seemed 


432    SYMPTOMS.  —  SUDDEN  DEATH  INEXPLICABLE  ;    [Part  II, 

formed  by  innumerable  intersecting  fibres,  giving  it  in  minia- 
ture the  appearance  of  tlie  urinary  bladder,  when  the  muscular 
coat  is  somewhat  thickened  ;  the  submucous  layer  was  thick- 
ened, and  that  forming  the  bottom  of  the  ulcerations  very 
brittle.  The  cystic  duct  was  very  narrow  near  its  junction 
with  the  hepatic,  and  contained  several  calculi.  The  ductus 
choledocus  was  healthy.  Liver,  spleen,  pancreas  and  kidneys 
were  natural.  Some  tuberculous  granulations  in  the  renal 
capsules.  Mucous  membrane  of  the  stomach,  of  a  pinkish- 
grey  tint,  nearly  every  where  maraillated,  being  thicker  in 
these  portions  than  elsewhere  ;  near  the  pylorus  it  was 
destroyed  over  a  very  small  surface.  Some  of  the  ellip- 
tical patches  of  the  small  intestine  were  ulcerated.  Lining 
membrane  of  the  colon  thick  and  softened,  with  numerous 
small  ulcerations  becoming  rarer  from  above  downwards. 
Mesenteric  glands,  healthy. 

460.  Here,  as  in  the  two  preceding  observations,  the  cause  of 
the  sudden  death  remains  unexplained.  We  shall  not  attempt 
to  attribute  it  to  the  softened  condition  of  the  brain,  for  we  are 
quite  ignorant  what  degree  of  firmness  is  necessary  for  the 
support  of  life  ;  we  may,  however,  observe  that  we  cannot 
pay  too  much  attention  to  all  alterations  in  the  consistence  of 
our  organs.  The  researches  of  MM.  Rostan  and  Lallemand 
have  thrown  much  light  on  the  partial  softenings  of  the  brain  ; 
it  remains  to  be  shown  when  a  general  softening  of  this  organ, 
always  easily  recognised  by  those  accustomed  to  pathological 
researches,  may  be  regarded  as  a  morbid  condition  ;  it  is  for 
the  purpose  of  assisting  in  the  solution  of  this  question  that  we 
detail  the  following  observation,  which  is  also  an  example  of 
latent  tubercles. 

461.  The  condition  of  the  brain  was  not  the  only  remarka- 


Chap.   10.]  SOFTENING    OF    THE    BRAIN.  433 

ble  circumstance  in  the  fact  before  us  ;  the  extensive  mamil- 
lated  state  of  the  gastric  mucous  membrane,  its  thickening, 
over  the  same  part,  and  loss  of  substance  near  the  pylorus, 
are  not  without  interest  if  we  compare  them  with  the  symp- 
toms present  during  the  two  years  preceding  death  ;  that  is, 
pains  in  the  epigastrium  and  diminished  appetite.  These  are 
indeed  the  symptoms  of  chronic  gastritis,  and  may  in  common 
with  the  mamillated  state,  have  resulted  from  it,  though  the 
presence  of  other  complications  render  our  conclusions  less 
positive.  Let  us  also  notice  the  relation  existing  between  the 
biliary  calculi,  the  thickened  and  ulcerated  state  of  the  gall- 
bladder, the  pains  under  the  short  ribs,  and  lastly,  the  jaun- 
dice, which  occurred  several  times  in  the  course  of  the  same 
year. 


FIFTIETH     OBSERVATION. 

462.  A  COOK,  set.  48,  of  middle  stature,  moderate  embou' 
point,  great  sensibility,  had  always  enjoyed  good  health  pre- 
vious to  her  present  illness.  The  catamenia,  which  first 
appeared  in  her  eighteenth  year,  were  suppressed  at  the  age 
of  thirty  ;  their  usual  period  was  every  six  weeks,  they  were 
always  scanty,  and  only  of  some  hours  duration.  Three  years 
before  her  admission  into  the  hospital  she  suffered  much  men- 
tal anxiety  from  being  unjustly  deprived  of  her  savings,  and 
was  suddenly  seized  with  loss  of  sensation  and  of  motion,  but 
her  intellectual  faculties  were  not  affected.  Wishing  to  die, 
she  refused  all  treatment,  and  continued  in  this  condition  about 
two  months.  She  was  then  attacked  by  pains  in  the  limbs, 
g3 


434    SYMPTOMS.  —  SUDDEN  DEATH  INEXPLICABLE  J    [Part  II, 

and  soon  afterwards  by  some  convulsive  movements  in  the  hands 
and  feet.  The  progress  of  the  disease  was  very  gradual,  and 
eight  months  elapsed  before  the  patient  could  resume  her  oc- 
cupations. She  continued  in  good  health  during  the  succeed- 
ing six  months,  when  she  was  attacked,  without  evident  cause, 
by  erysipelas  in  the  left  leg.  An  empiric  made  her  anxious 
about  the  consequences  of  this  affection,  and  immediately  the 
mucous  secretion  of  the  nasal  fossae  and  a  leucorrhcea,  to 
which  she  had  been  liable  from  childhoood,  were  suppressed  ; 
a  spitting  of  blood,  also,  which  had  occurred  frequently 
from  the  same  period,  came  on  both  morning  and  evening, 
and  was  attributed  by  the  patient  to  the  unhealthy  state 
of  her  gums.  At  the  same  time  an  epistaxis,  to  which 
she  was  frequently  liable,  ceased.  She  experienced  a  sense  of 
weight  in  the  frontal  sinuses,  and  lost  her  smell  and  taste  ; 
the  appetite  was  not  affected.  The  suppressed  evacuations 
did  not  return,  and  the  patient  never  recovered  her  usual  good 
spirits.  Three  weeks  before  her  admission  into  the  hospital 
she  was  seized  with  violent  headache,  accompanied  with  heat 
and  thirst,  which  co  nfinedher  to  her  bed  five  days.  There 
were  no  other  symptoms  ;  she  was  not  liable  to  colds,  and  did 
not  cough. 

Feb.  16th,  1822.  The  day  after  her  admission  into  La  Char- 
ité, the  intellectual  faculties  were  unaffected  ;  there  was  slight 
headache  ;  complete  loss  of  both  taste  and  smell  ;  the  nose 
enlarged  at  its  base  and  laterally.  This  was  attributed  to  the 
habit,  since  she  had  ceased  blowing  her  nose  with  a  handker- 
chief, of  extracting  the  dried  mucus  with  her  fingers  ;  little 
general  debility.  Tongue,  natural  ;  thirst,  rather  urgent  ; 
little  appetite  ;  stools,  natural  ;  pulse,  calm  ;  heat  moderate  ; 
respiration,  easy  ;  no  evident  emaciation. 

(Decoction  of  dulcamara  ;  occasional  sulphur  baths  ;  blister 
to  the  arn)  ;  one  eighth  of  the  house  allowance.) 


Chap.    10.]  SOFTENING    OF    THE    BRAIN.  435 

The  headache  disappeared,  but  returned  slightly  on  the  20th 
of  February,  after  exposure  to  a  cold  wind.  22d.  It  had  much 
diminished  ;  the  appetite  was  improved  and  thirst  gone.  23d. 
Nothing  remarkable.  24th.  At  ten,  p.  m.,  she  complained 
of  a  sense  of  heat,  general  uneasiness,  and  a  feeling  of  swell- 
ing and  fulness  in  the  face.  Two  hours  afterwards  she  ex- 
pired. 

Opening  of  the  corpse  thirty-two  hours  after  death. 

Exterior.  —  Some  ecchymoses  on  the  surface  of  the  skin  ; 
great  rigidity  of  limbs. 

Head.  —  Brain,  extremely  pale,  very  soft  throughout  its 
whole  extent,  like  that  of  a  new-born  child  ;  the  olfactory 
nerves  were  natural  ;  mucous  membrane  of  the  nasal  fossae, 
healthy  ;  that  of  the  frontal  and  maxillary  sinuses  was  a  line 
and  a  half  thick,  infiltrated,  serai-transparent,  firm,  and  in 
color  like  the  pulp  of  a  baked  apple  ;  there  was  no  dried  mu- 
cus in  these  parts. 

Neck.  —  Glottis,  epiglottis  and  larynx,  natural. 

Thorax.  —  Some  adhesions  over  the  summit  of  the  left 
lung  ;  five  crude  tubercles,  about  the  size  of  a  small  walnut  in 
the  summit,  surrounded  by  a  little  grey,  semi-transparent  sub- 
stance, and  enclosing  four  nuclei,  of  a  bony  earthy  structure  j 
the  posterior  portion  of  both  lungs  was  slightly  engorged; 
bronchia,  pale  and  thin. 

Abdomen.  —  Convex  surface  of  the  liver,  very  uneven,  in- 
tersected by  variously  directed  depressions,  which  gave  it  the 
aspect  of  the  cerebral  convolutions  ;  the  structure  of  the  organ 
was  healthy,  and  rather  congested,  especially  in  the  large  lobe. 
The  gastric  mucous  membrane  was  of  a  bluish-grey  color,  with 
here  and  there  a  pink  tinge  ;  that  of  the  small  intestine,  natu- 


436      SYMPTOMS.  SUDDEN  DEATH  INEXPLICABLE  ;    [Part  11, 

ral  ;  the  kidneys  were  much  congested  ;  spleen,  firm,  volumi- 
nous, pale  ;  the  other  viscera  were  healthy. 

463.  Without  any  desire  to  assign  any  cause  for  the  sudden 
death  of  this  patient,  we  would  remark  that  the  state  of  the  brain 
in  this  observation  is  very  analogous  with  that  in  the  prece- 
ding, as  are  also  the  cerebral  symptoms.  Both  patients  were 
of  nearly  the  same  age  (forty-eight  and  fifty-four),  and  at  a 
period  of  life  when  the  brain  is  naturally  very  consistent, 
while  in  these  instances,  although  the  patients  died  suddenly, 
it  was  not  firmer  than  that  of  a  new-born  infant.  This  great 
deviation  from  the  normal  state  appears  to  us  an  evident  mor- 
bid condition,  and  this  opinion  is  confirmed  by  the  symptoms, 
vi'hich'could  not  have  been  caused  by  any  thing  except  the 
brain.  In  the  one  case  we  had  vertigo,  flushings  of  the  face, 
sudden  weakness  of  the  limbs,  of  short  duration,  and  frequent- 
ly recurring  during  a  period  of  thirty  years  ;  these  attacks 
became  more  frequent  the  last  six  months,  and  were  asso- 
ciated with  numbness  of  the  extremities,  which  lasted  half  an 
hour,  and  then  entirely  ceased  ;  the  intellectual  faculties  were 
never  affected.  In  the  other  case  there  was  complete  paraly- 
sis of  motion  and  sensation  three  years  before  death  ;  this 
continued  unabated  two  months,  gradually  disappearing  at  the 
end  of  eight  months,  and,  as  in  the  preceding  case,  the  intel- 
lectual faculties  remained  undisturbed.  In  both,  the  cerebral 
symptoms  had  ceased  two  years  before  death.  If  the  symp- 
toms are  not  exactly  similar,  they  are  at  least  very  analo- 
gous ;  and  the  greatest  softening  of  the  brain  occurred  in 
the  case  in  which  the  symptoms  had  been  most  intense  ;  so 
that  we  must  necessarily  suppose  some  dépendance  between 
the  state  of  the  brain  and  the  symptoms  observed.  If,  how- 
ever, this  should   not   be  fully  admitted,  the  facts  may  excite 


Chap.  IL]  CAUSES  of  phthisis.  437 

further  investigation  on  the  part  of  observers,   and  this  is  our 
chief  object. 

We  shall  not  enlarge  on  the  sudden  suppression  of  the  nasal 
and  buccal  secretions,  &c.,  but  we  would  remark  that  the  tuber- 
cles in  the  left  lung  were  latent,  and  had  not  excited  cough  ; 
that  the  patient  was  not  liable  to  bronchitis,  that  the  bronchia 
were  healthy,  and,  consequently,  nothing  can  justify  the  sup- 
position that  the  tubercles  resulted  from  their  chronic  inflam- 
mation. As~was  the  case  in  the  majority  of  the  instances  of 
sudden  death,  there  were  vibices  on  the  extremities. 


CHAPTER   XI. 

CAUSES  OF  PHTHISIS, 


464.  A  KNOWLEDGE  of  the  causes  of  disease  is  without 
doubt  of  the  highest  importance  in  medicine;  for,  if  not  al- 
ways available  for  treatment,  it  often  enables  us  to  adopt  pro- 
phylactic measures  ;  and  this  consideration  alone  explains  the 
interest  attending  the  study  of  the  causes  of  phthisis,  and 
the  great  attention  their  investigation  has  received.  Unfor- 
tunately, as  is  the  case  in  many  other  circumstances,  asser- 
tion is  much  easier  than  proof,  and  the  detection  of  error  than 
the  discovery  of  truth,  so  that  little  really  satisfactory  has  as 
yet  been  effected.  Our  own  observations  have  not  demon- 
strated the  cause  of  tubercles  in  the  lungs,  but  they  have 
brought  us  to  conclusions  opposed  to  the  doctrine  of  irritation, 
and  on  this  account  we  think  it  useful  to  expose  the  results  of 
our  investigations. 


438                                     CAUSES  ;  [Part  II, 

465.  We  shall  successively  examine  the  influence  of  sex, 

pneumonia,   pleurisy,  bronchitis,   &tc,,  on    the   production  of 
phthisis. 


INFLUENCE  OF  SEX. 

466.  We  have  already  said  that  the  one  hundred  and 
twenty-three  observations  of  phthisis  were  collected  during 
rather  more  than  three  years,  in  wards  containing  forty-eight 
beds,  equally  divided  between  men  and  women.  Sixty-six  of 
these  cases  belonged  to  the  latter,  fifty-seven  to  the  men,  which 
seems  to  indicate  the  greater  liability  of  women  to  phthisis. 
This  now  is  strengthened  by  another  fact.  In  an  equal  num- 
ber of  patients  of  both  sexes  who  have  died  from  other  chronic 
affections,  we  have  found  tubercles  in  the  lungs  twenty-five 
times  in  women,  and  only  fifteen  times  in  men  ;  that  is,  by 
joining  these  two  results,  the  proportion  of  phthisical  cases 
in  men  and  women,  was  as  seventy  to  ninety-two  ;  a  differ- 
ence very  considerable  in  favor  of  the  weaker  sex.* 


INFLUENCE  OF  PNEUMONIA  AND  PLEURISY. 

467.  In  eighty  cases  of  phthisis,  where  we  have  carefully 
endeavored  to  learn  the  diseases  existing  anteriorly  to  the 
tubercular  affection,  three  had  pneumonia  four  years  before 
death,  and  from  that  time  the  cough  and  expectoration  had  con- 
tinued ;  four  had  the  same  disease  three,  six,  and  fifteen  years 
previous  to  the  appearance  of  the  first  symptoms  of  phthisis, 
without  having  incurred  greater  liability  to  colds  during  the 

*  See  Translator's  Appendix,  C.  —  H.  I.  B. 


Chap.   IL]    INFLUENCE  OF  PNEUMONIA  AND  PLEURISY.       439 

same  period,  or  having  been  subject  to  dyspnœa.  All 
were  of  a  feeble  constitution  and  of  the  lymphatic  tempera- 
ment; that  is,  they  presented  those  characters  which  phy- 
sicians have  classed  among  the  principal  predisposing  causes 
of  phthisis.  These  observations  mutually  destroy  one  another 
in  reference  to  the  point  now  under  consideration,  and,  there- 
fore, all  that  we  can  deduce  from  them  is,  that  pneumonia 
exerts  no  influence  in  the  development  of  phthisis. 

468.  It  will  doubtless  be  said,  that  this  conclusion  is  falsi- 
fied by  a  great  number  of  facts,  particularly  by  the  observa- 
tions of  M.  Broussais.  Without  disputing  the  accuracy  of 
these  facts,  we  cannot  help  thinking  that  we  ought  not  to 
deduce  from  them  what  has  been  heretofore  deduced.  Acute 
and  chronic  pneumonia  and  pleurisy  are  very  common  in  the 
army  ;  M.  Broussais,  who  has  examined  a  number  of  cases 
fatal  from  both  of  these  diseases,  has  found  in  many  of  thenn 
tubercles  in  the  lungs,  and  has  hence  considered  pleurisy 
and  pneumonia  as  their  cause.  To  render  this  conclusion 
rigorous,  tables  of  mortality  were  necessary  for  the  pur- 
pose of  ascertaining  whether  the  lungs  under  these  circum- 
stances were  more  frequently  tuberculated  than  in  individuals 
of  the  same  age,  dying  in  the  civil  hospitals,  in  a  time  of 
peace.  Without  this  confirmative  evidence,  the  proposition 
of  M.  Broussais  is  wholly  conjectural,  since  instead  of  dépen- 
dance, there  may  have  been  a  simple  coincidence  merely  be- 
tween two  diseases  in  other  respects  so  different  ;  this  is  ren- 
dered still  more  probable  from  the  consideration,  that  the 
period  of  life  when  tubercles  are  most  frequent  (fi-om  twenty 
to  thirty)  (481),  was  precisely  that  in  which  M.  Broussais  so 
often  observed  pneumonia  and  pleurisy.  These  observations 
are  not  only  incapable  of  proving  pneumonia  to  be  a  cause  of 
tubercles,  but  the  history  of  the  disease  itself  rather  favors  a 


440  CAUSES  ;  [Part  II, 

contrary  supposition.  It  is,  in  fact,  (Bayle)  most  usually  de- 
veloped from  the  base  to  the  summit  of  the  lungs,  while  the 
reverse  is  the  case  for  tubercles  ;  pneumonia  seldom  attacks 
both  sides  of  the  chest,  while  phthisis  almost  invariably  occu- 
pies both  lungs.  Phthisis  is  more  frequent  in  women  than 
men  ;  the  inverse  holds  good  for  pneumonia.  Out  of  seventy- 
five  patients  attacked  by  the  latter  disease,  whose  histories  we 
have  collected  during  the  last  three  years,  twenty-three 
only  were  women  :  eighteen  died,  —  fifteen  men  and  three 
women. 

469.  The  same  reflections  are  equally  applicable  to  pleu- 
risy. We  have  found  it  more  frequently  in  men  than  women  ; 
it  was  generally  confined  to  one  side  of  the  chest,  and  if  we 
have  often  discovered  tuberculous  granulations  in  the  lungs  in 
fatal  cases  of  chronic  pleurisy,  they  were  equally  numerous 
on  the  sides  of  the  chest  where  the  pleurisy  did  not  exist,  as 
on  the  other. 

470.  These  facts  are  evidently  much  opposed  to  the  doc- 
trine of  irritation.  We  are,  however,  far  from  asserting  that 
pneumonia  can  exercise  no  influence  in  tubercular  develop- 
ment, for  who  can  prescribe  bounds  to  what  is  possible  ?  But 
this  influence  appears  as  yet  but  mere  conjecture,  and  we 
think  it  can  only  be  demonstrated  by  means  of  the  tables  of 
mortality  already  alluded  to,  by  which  the  diseases  of  indi- 
viduals who  had  died  in  various  circumstances  may  be  con- 
trasted with  each  other. 

However,  supposing  for  a  moment  that  such  an  influence 
really  does  exist,  it  cannot  be  very  considerable,  since  among 
the  somewhat  numerous  facts  we  have  carefully  collected,  we 
have  found  no  evidence  in  its  favor.* 

*  See  Translator's  Appendix,  D.  —  H.  I.  B. 


Chap.    11.]  INFLUENCE    OF    BRONCHITIS.  441 


INFLUENCE  OF  BRONCHITIS. 

471.  This  influence  does  not  seem  to  be  demonstrated  more 
fully  than  that  of  pneumonia.  Out  of  eighty  individuals  who 
distinctly  recollected  the  symptoms  they  had  experienced  ante- 
riorly to  the  origin  of  phthisis,  only  twenty-three  were  subject 
to  catarrh  ;  fifty-two,  or  about  two  thirds,  being  rarely  affect- 
ed. What  conclusion  are  we  to  draw  from  this  ?  —  that 
phthisis  is  equally  frequent  in  individuals  liable  to  bronchitis, 
as  in  those  where  no  such  liability  exists  ;  it  cannot,  therefore, 
be  considered  as  a  consequence  of  the  latter,  no  evident  rela- 
tion existing  between  them. 

Another  class  of  facts  will  lead  us  to  the  same  conclusion. 
Women,  who  are  more  frequently  attacked  by  phthisis  than 
men,  are  less  subject  to  bronchitis,  or  at  least  to  that  kind  of 
bronchitis  which  is  sufficiently  intense  to  require  treatment. 
Out  of  one  hundred  and  forty-nine  cases,  collected  during  the 
last  three  years,  fifty-two  only,  or  about  one  third,  were 
women. 

472.  Whether,  therefore,  we  investigate  the  connexion 
-which  exists  between  inflammation  of  the  substance  of  the 
îung  or  of  the  bronchial  membrane  and  phthisis,  we  arrive 
at  the  same  conclusion,  viz.,  the  sex  luhich  seems  the  most  ex- 
posed to  phthisis  is  least  frequently  attacked  by  pneumonia 
or  bronchitis  ;  and  this  in  the  proportion  of  one  to  three. 

The  opinion  then,  that  pulmonary  tubercles  are  the  result 
of  chronic  inflammation  of  the  bronchial  mucous  membrane, 
pulmonary  parenchyma  or  pleura,  on  whatever  theory  it  may 
be  supported,  is  quite  unsatisfactory  ;  the  preceding  results 
cannot  be  set  aside,  except  by  a  larger  series  of  observations, 
H  3 


442  CAUSES  ;  [Part  II, 

which  shall  prove   that  the  proportion   we  have   established 
resulted  from  a  purely  accidental  combination  of  facts. 

473.  But  if,  contrary  to  all  probability,  our  observations 
should  be  thought  not  sufficiently  numerous  to  establish  the 
relative  proportion  of  phthisis  in  men  and  women,  our  con- 
clusions would  not  on  that  account  be  invalidated,  since  the 
relative  frequency  of  phthisis,  compared  with  that  of  pneu- 
monia or  bronchitis  in  either  sex,  would  still  remain  unaf- 
fected. 

474.  If,  however,  by  a  series  of  well  observed  facts,  it 
should  appear  that  these  two  affections  really  exercise  an  in- 
fluence in  the  production  of  phthisis,  it  would  still  be  undecid- 
ed whether  they  were  a  necessary  cause,  and  whether  phthisis 
depended  upon  their  presence  ;  our  observations  on  acute 
phthisis  seem  distinctly  to  prove  the  contrary.  The  first  is 
relative  to  a  young  woman  who  was  not  subject  to  colds  (Obs, 
33),  had  never  had  pneumonia  and  was  in  perfect  health  up  to 
the  moment  when  she  was  attacked  with  fever,  which  was 
soon  followed  by  cough  and  expectoration  ;  she  died  on  the 
thirty-fifth  day  of  her  illness,  and  twenty-fifth  from  the  com- 
mencement of  the  cough  ;  after  death  we  found  a  large  mass  of 
tuberculous  matter  at  the  base  of  one  of  the  lungs,  softened  and 
partially  excavated,  with  grey  granulations,  he.  he.  These 
morbid  productions  were  certainly  not  the  result  of  bronchial 
inflammation  ;  to  support  the  contrary  idea,  we  must  prove 
that  bronchitis  of  twenty-four  hours  duration  could  have  produc- 
ed tuberculous  deposit,  he.  But  we  respect  the  reader  too 
much  to  suppose  him  supporting  such  an  opinion,  or  other 
equally  improbable  suppositions,  and  shall  consider  the  fact  of 
phthisis  being  developed  independently  of  all  inflammation, 
as  satisfactorily  as  possible  demonstrated  in  the  instance  be- 
fore us. 


Chap.    11.]  INFLUENCE    OF    BRONCHITIS.  443 

475.  The  other  observations  of  acute  phthisis  are  equally- 
decisive  ;  we  shall  mention  particularly  the  thirty-fourth, 
that  of  a  man,  usually  enjoying  good  health,  suddenly  seized, 
without  any  evident  cause,  with  fever,  then  cough,  and  who 
died  on  the  thirtieth  day  from  the  commencement  of  the 
symptoms.  The  lungs  were  filled  by  an  immense  number  of 
grey,  semi-transparent  granulations,  the  bronchial  mucous 
membrane  being  perfectly  healthy,  with  the  exception  of  a 
slight  livid  tint,  doubtless  produced  by  simple  congestion  to- 
wards the  close  of  life,  and  which  is  frequently  observed  in 
cases  of  sudden  death.  We  would  also  recall  the  thirty-fifth 
observation,  relative  to  a  young  man,  aged  nineteen,  in  per- 
fect health  until  attacked,  without  any  assignable  cause,  by 
fever  and  cough,  and  in  whom  there  was  sufficient  tuberculous 
matter  developed  in  the  lungs  on  the  twentieth  day,  to  render 
the  percussion  of  the  chest  dull.  We  might  also  cite  obser- 
vations thirty-six  and  thirty-seven,  and  especially  the  tenth 
(bis),  in  which  there  was  dulness  of  sound  under  the  right 
clavicle  on  the  seventeenth  day,  although  in  this  instance,  the 
fatal  termination  was  not  equally  rapid.  Out  of  one  hundred 
and  twenty-three  cases,  therefore,  six  or  one  twentieth  of  the 
whole  were  direct  illustrations  of  the  production  of  phthisis, 
independently  of  all  inflammatory  action,  either  in  the  sub- 
stance of  the  lung  or  in  the  bronchial  mucous  membrane. 

476.  The  same  fact  may  also  be  deduced  from  our  exam- 
ples of  latent  phthisis.  Three  among  them  (Obs.  27,  28, 
29),  were  instances  of  simple  phthisis  ;  the  cough  and  expec- 
toration had  been  preceded,  during  six  or  twelve  months,  by  a 
continued  fever  with  slight  remissions  ;  and  from  the  absence 
of  all  cotTi plications,  this  fever  could  only  be  the  result  of  the 
presence  of  tubercles,  which  were  here  not  produced  by  either 
pneumonia  or  bronchitis.     Observation  fourth  is  also  in  support 


444  .  CAUSES  ;  [Part  II, 

of  this  assertion,  for  here  the  cough  and  expectoration  came  on 
after  four  months  of  violent  diarrhœa,  and  only  preceded  death 
six  weeks.  The  size  and  structure  of  the  excavations  were 
evident  proofs  of  the  presence  of  the  tuberculous  matter  ante- 
rior to  the  cough,  which  was  here  an  effect,  not  a  cause. 

477.  Not  only  then  is  the  influence  of  pneumonia,  pleurisy, 
and  bronchitis  in  the  development  of  phthisis  not  demon- 
strated, but  our  observations  induce  us  to  suppose  its  existence 
imaginary,  or  at  least  restricted  within  very  narrow  limits  ; 
from  what  has  preceded,  we  think  that  we  have  proved,  that  in 
one  twelfth  part  of  our  cases,  pulmonary  tubercles  were  devel- 
oped independently  of  all  inflammation,  either  of  the  substance 
of  the  lung,  pleurae,  or  bronchia. 

We  must,  however,  acknowledge,  that  the  slow  progress  of 
phthisis  in  the  greater  number  of  instances,  and  the  striking 
similarity  of  its  symptoms  to  those  of  simple  bronchitis  in  the 
first  stage,  and  the  inflammatory  state  of  a  part  of  the  bronchia 
so  frequently  present  in  cases  of  phthisis,  offer  an  easy  ex- 
planation of  why  inflammation,  and  more  especially  that  of 
the  bronchial  membrane,  should  have  been  regarded  as  a 
cause  of  tubercles  ;  we  think,  however,  that  in  the  majority 
of  cases  this  opinion  is  no  longer  tenable. 

478.  There  is  also  a  circumstance  not  less  certain  than 
those  on  which  we  have  hitherto  insisted,  and  which  might 
indeed  be  substituted  in  their  stead,  viz.  (36)  that  the 
bronchia  are  in  general  healthy  in  the  vicinity  of  either  un- 
softened  tubercles,  or  masses  of  grey,  semi-transparent  matter 
(Obs.  29,  he.)  ;  that  the  redness  and  thickening  of  those 
which  communicate  with  tuberculous  excavations,  seem  the 
result  of  the  constant  passage  of  the  contents  of  the  latter,  and 
that  in  cases  fatal  from  some  other  affection,  but  with  crude 
tubercles,  or  grey  granulations  in  the  lungs  (Obs.  50),  the 


Chap.   IL]  INFLUENCE    OF    DRESS.  445 

bronchia  are  almost  constantly  healthy,  both  as  to  color  and 
thickness.  Facts  of  this  description  are  not  uncommon  ;  we 
have  lately  encountered  several,  and  it  is  only  necessary  to 
have  met  a  single  example,  to  feel  convinced  that  in  many 
instances,  inflammation  and  tubercles  in  the  lungs  are  inde- 
pendent of  each  other.* 


INFLUENCE  OF  DRESS. 

479.  The  influence  of  dress,  and  especially  of  stays,  on  the 
production  of  phthisis,  is  also  perhaps  a  mere  assertion.  Sev- 
eral of  the  women  we  examined  were  liable  to  shortness  of 
breath  before  they  became  consumptive  ;  but  this  was  equally 
the  case  with  the  men  ;  so  that  if  we  should  admit  a  connexion 
between  this  peculiarity  in  dress  and  phthisis,  it  would  not  be 
correct,  even  if  they  have  been  worn  from  a  very  early  period 
of  life,  to  attribute  phthisis  to  stays.  Besides,  the  majority 
of  our  female  patients  had  been  educated  in  the  country,  were 
habituated  to  rustic  occupations,  and  had  only  been  accus- 
tomed to  stays  after  their  residence  in  Paris,  when  their  growth 
was  established,  or  in  other  words,  when  stays  could  not 
have  exerted  any  considerable  influence  on  the  dimensions 
of  the  chest.  Supposing,  however,  this  influence  to  have 
existed,  its  demonstration  would  be  exceedingly  difHcult,  for 
it  would  be  necessary  to  compare  a  great  number  of  women 
together,  some  of  whom  had  worn  stays  from  a  very  early 
period,  the  others  only  after  the  full  growth  of  their  bodies, 
to  be  enabled  to  decide  if  phthisis  was  more  frequent  in  one 
class  than  in  the  other.  The  influence  of  stays  in  phthisis, 
and  in  general  of  those  causes  which  interfere  with  the  devel- 

*  See  Translator's  Appendix,  E.  —  H.  I.  B, 


446  CAUSES  ;  [Part  lï, 

opraent  of  the  frame,  is  still  more  problematical,  from  the  fact 
that  tubercles  are  nearly  equally  frequent  in  individuals  of  a 
strong  as  in  those  of  a  feeble  constitution.* 


HEREDITARY  INPLUENCE.f 

480.  One  tenth  of  our  patients  were  children  of  parents, 
one  or  both  of  whom  appeared,  as  far  as  we  could  judge,  to 

*  "  The  deposition  of  the  peculiar  matter  of  tubercle  in  any  of  the  tissued 
or  organs  of  the  body,  is  only  the  result  of  previous  changes  in  the  general 
system,  cognizable,  as  we  have  endeavored  to  show  by  the  physical  con- 
dition of  the  patient,  and  by  a  disordered  state  of  various  functions  ;  a  con- 
dition  of  the  body  quite  distinct  from  mere  debihly,  and  therefore  inexplicable 
on  the  idea  of  a  difference  of  force  or  tone  of  the  system,  and  which,  though 
very  generally  accompanied  with  a  feeble  organization,  is  not  inconsistent 
with  too  great  development  and  inordinate  action  of  particular  parts,  and 
even  with  considerable  physical  power  of  the  system."  —  Article  on  tuber- 
cular Phthisis. —  Cycl.  Pract.  Med.  page  325.  §  — Ccwan. 

t  There  can  be  but  little  doubt  that  as  a  general  principle,  children  born 
from  healthy  parents  are  more  robust  than  those  in  opposite  circumstances, 
and  on  this  account  are  less  predisposed  to  disease.  The  evidence  hitherto 
adducedin  favor  of  the  hereditary  nature  of  phthisis,  amounts  to  little  more 
than  the  announcement  of  this  fact,  and  while  we  cannot  help  admitting, 
in  the  children  of  consumptive  parents,  a  predisposition,  there  is  no  reason 
to  suppose  that  in  the  majority  of  instances,  prophylactic  treatment  would 
not  be  attended  with  success.  The  fact  of  tubercles  being  found  in  the 
foetus,  only  proves  that  phthisis  is  one  of  the  many  diseases  which  may  bet 
developed  before  birth,  and  we  have  no  reason  to  believe  that  it  may  not 
arise  from  any  cachexia  in  the  parent  which  interferes  withs  the  proper 
nutrition  of  the  child,  as  well  as  from  the  tuberculous.  In  general  terms 
it  may  be  stated  that  children  are  hereditarily  predisposed  to  phthisis  in 
proportion  as  their  general  health  is  enfeebled,  whatever  may  be  the  cause, 
and  that  attention  to  this  fact  is  of  more  practical  importance  to  the  physi- 
cian, than  the  knowledge  of  whether  tuberculous  disease  did  or  did  not 
exist  on  the  part  of  parents.  —  Cowajv. 


§  Sec  Translator's  Appendix,  F.  —  H.  I.  B. 


Chap.   11.]        HEREDITARY    INFLUENCE;    AGE.  447 

have  died  of  phthisis  ;  but  as  the  disease  could  have  been 
transmitted  or  spontaneously  developed,  and  since  we  are 
ignorant  of  the  cause  of  death  in  their  brothers  and  sisters,  it 
follows  that  we  have  not  collected  any  fact  in  favor  of  the 
hereditary  nature  of  phthisis.  We  do  not  wish  to  imply  that 
this  hereditary  influence  is  doubtful,  for  too  many  examples 
seem  to  justify  an  opposite  opinion  ;  and  probably  also  the 
proportion  we  have  mentioned  of  individuals  born  from  con- 
sumptive patients,  is  too  small,  from  the  difficulty  which  in 
hospitals  attends  the  investigation  ;  but  we  believe,  that  to 
determine  the  question  satisfactorily,  tables  of  mortality  would 
be  necessary,  comparing  an  equal  number  of  persons  born  of 
phthisical  parents  with  those  in  an  opposite  condition. 


INFLUENCE  OF  AGE. 

481.  Of  this  there  is  no  doubt;  the  number  of  deaths  from 
phthisis,  is  more  considerable  from  twenty  to  forty,  than  from 
forty  to  sixty,  although  the  absolute  mortality  is  less  in  the  first 
than  in  the  second  period.  This  fact  has  already  been  proved 
by  Bayle,  and  our  own  observations  are  confirmative  of  his 
with  some  slight  variations.*  Phthisis  is  distributed  in  the 
different  ages  as  follows  :  — 

Between  the  ages  of  according  to  our  notes  according  to  Baylo's 

15  and  20,  11  died  ;  10  died. 

20  "  30,  39  "  23  " 

30  "  40,  33  "  23  " 

40  "  50,  23  *'  21  «' 

50  "  60,  12  "  15  " 

60  "  70,  5  «  8  « 

*  Seo  Tianalator's  Appendix,  G.  —  H.  I.  B. 


448  TREATMENT  ;  [Part  II, 


CHAPTER    XII. 

TREATMENT. 

482.  It  was  simple,  and  varied  according  to  the  indica- 
tions. These  were  founded  on  the  state  of  the  functions,  and 
the  different  comphcations  occurring  in  the  progress  of  the 
principal  disease, 

483.  Upon  the  arrival  of  the  patient,  if  there  was  very  little 
or  no  fever,  no  thoracic  complication,  (as  pleurisy,  pneu- 
monia, haemoptysis,  &ic.),  and  if  the  digestive  functions  were 
not  deranged,  we  prescribed,  whatever  might  have  been  the 
stage  of  the  disease,  the  decoction  of  Iceland  moss,  a  gum 
potion,  and  frequently  small  doses  of  syrup  of  poppies  to  allay 
the  cough  and  procure  sleep.  One  fourth  or  an  eighth  of  the 
usual  house  allowance  was  given  in  proportion  to  the  appetite  ; 
the  food  was  afterwards  either  increased  or  diminished,  as  cir- 
cumstances pointed  out. 

484.  When  fever  was  present  without  local  inflammatory 
symptoms,  as  was  the  case  in  the  second  stage,  we  ordered 
infusion  of  the  pectoral  flowers,  a  gum  potion,  some  broth, 
with  two  rice  creams  daily.  Under  this  regimen  the  violence 
of  the  fever  abated,  and  there  was  general  improvement  in  all 
the  functions  ;  the  thirst  was  less  urgent;  the  appetite  in- 
creased_^;  the  breathing  became  less  oppressive,  and  the  expec- 
toration more  easy  ;  the  food  was  always  regulated  by  the  state 
of  the  patient  and  his  appetite  ;  vegetables  and  frequently  milk 
were  allowed.  This  amelioration  was  more  or  less  perma- 
nent, but  after  a  certain  time  some  complication  invariably 
supervened,  requiring  a  change  in  the  treatment. 


Chap.   12.]  TREATMENT.  449 

485.  If  the  patients  entered  the  hospital  soon  after  the 
commencement  of  the  disease,  and  if  the  symptoms  were  more 
or  less  acute,  the  infusion  of  violets,  a  simple  gam  potion,  diet, 
and  usually  venesection  in  proportion  to  the  strength,  were 
prescribed.  Leeches  were  also  applied  to  the  labia  when  the 
catarnenia  were  suppressed  or  irregular,  but  only  when  the 
disease  was  not  chronic  in  its  progress,  and  when  fever  was 
present.  Bleeding,  either  local  or  general,  under  these  cir- 
cumstances, exerted  little  or  no  influence  over  the  disease. 

486.  When  the  cough  was  very  troublesome  during  the 
night,  we  prescribed  at  first  an  ounce  or  half  an  ounce  of  syrup 
of  poppies  in  the  evening,  and  if  this  did  not  succeed,  we 
ordered  a  gum  potion  with  doses  of  opium,  gradually  increased, 
from  one  to  three  grains.  In  some  cases  in  which  this  remedy 
was  used  without  success,  the  acetate  of  morphia  and  extract 
of  belladona  were  successively  tried  without  any  additional 
success.  In  four  cases  where  opium,  under  every  form,  had 
failed,  it  was  given  during  the  day  in  doses  of  from  one  to  two 
grains,  without  any  diminution  of  the  cough  ;  in  three  of 
these  it  was  suppressed  because  it  occasioned  pains  in  the 
throat.  These  pains  were  pungent,  with  a  sense  of  dryness 
and  slight  hoarseness  coming  on  half  an  hour,  an  hour,  or 
even  sooner,  after  the  pill  was  swallowed  ;  the  deglutition  was 
also  difficult,  though  there  was  no  redness  of  the  pharynx  or 
amygdalae.  These  symptoms  returned  whenever  belladonna 
was  taken,  and  persisted  from  two  to  three  hours. 

487.  Pleuritic  pains,  at  whatever  period  they  occurred, 
when  urgent,  required  particular  attention.  If  present  in  the 
earlier  periods  of  the  disease,  and  accompanied  with  fever, 
venesection  was  prescribed  and  repeated  if  necessary,  accord- 
ing to  the  strength  of  the  patient  and  violence  of  the  symp- 

I  3 


450  TREATMENT.  [Part  II, 

toms  ;  leeches  were  then  applied  and  afterwards  a  blister. 
Under  this  treatment  the  symptoms  abated,  but  did  not 
wholly  disappear  ;  the  effusion  was  not  completely  absorbed, 
and  the  pains  occasionally  returned.  At  a  more  advanced 
period,  when  the  emaciation  and  debility  were  considerable, 
some  leeches  or  a  small  blister  were  the  only  remedies  re- 
sorted to. 

Pneumonic  symptoms  were  treated  precisely  in  the  same 
way,  and,  as  we  have  already  remarked,  with  success. 

488.  Venesection  was  also  employed  in  cases  of  copious 
haemoptysis;  but  although  carried  to  great  extent  in  three 
instances  (Obs.  16,  42),  it  failed  to  arrest  the  hsemorrhage, 
for  it  came  on  after  the  venesection,  in  the  midst  of  the  most 
perfect  calmness  of  the  patient,  just  as  if  the  individual  had 
committed  some  error  in  diet.  In  one  case  (Obs.  10),  a  large 
blister  was  applied  between  the  shoulders,  without  any  evident 
success;  in  another  (Obs.  42),  the  haemorrhage  was  not 
arrested  until  after  the  administration  of  a  gum  potion,  with 
half  a  drachm  of  the  powder  of  ratanhy  root.  On  the  first  day 
that  this  was  used  the  haemoptysis  was  much  diminished,  and 
on  the  third  ceased  altogether.  If  the  haemoptysis  was  slight, 
or  if  the  expectoration  only  presented  a  red  tint,  and  the 
debihty  very  considerable,  we  confined  ourselves  to  demulcent 
drinks,  hand  and  foot  baths,  enemata  and  diet.  In  some 
cases,  under  these  circumstances,  a  very  small  bleeding  was 
practised  with  evident  success,  the  red  color  of  the  sputa  dis- 
appearing very  soon  after  the  vein  was  opened. 

489.  In  six  cases  in  which  the  dyspnœa  was  considerable 
and  there  was  no  disease  of  the  heart,  or  acute  affection  of  the 
lungs,  blisters  were  applied  over  the  sternum,  with  relief  in  two 
cases.  When  the  same  application  was  made  to  the  arm, 
the  patient  never  appeared  benefited  in   any  way,  whether 


Chap.    12.]  TREATMENT.  451 

it  was  made  before  or  after  entrance  into  the  hospital.  In 
four  examples  of  acute  phthisis,  blisters  were  also  applied  to 
the  chest  after  venesection,  without  any  decrease  of  the  op- 
pression, fever,  or  cough  ;  so  that  bleeding  and  derivatives 
have  failed  in  the  majority  of  those  cases  we  have  observed. 

490.  In  three  of  the  instances  where  the  alteration  of  the 
voice  and  pains  in  the  larynx  indicated  ulcerations  in  this 
region,  leeches  were  twice  applied  to  the  neck  and  were  suc- 
ceeded by  a  blister,  without  any  success.  This  treatment  was 
opposed  to  the  ulcerations  of  the  trachea  (usually  indeed  giving 
rise  to  no  symptoms),  but  from  their  frequency,  as  well  as 
those  of  the  epiglottis  and  larynx,  the  application  of  medicated 
vapors  at  a  certain  period  of  the  disease,  would  perhaps  be 
advantageous. 

491.  The  sulphate  of  quinine  was  given  in  some  cases 
where  the  rigors  were  very  troublesome  and  regular  in  their 
recurrence  ;  they  diminished  or  disappeared  entirely  after  the 
use  of  the  febrifuge,  but  the  heat  persisted,  and  the  rigors  also 
returned  when  the  remedy  was  abandoned.  In  one  case 
(Obs.  41),  its  suppression  was  necessitated  by  the  oppression 
at  the  epigastrium,  &:c.,  which  it  occasioned. 

492  In  six  cases  the  acetate  of  lead  was  employed  to  check 
the  perspirations,  in  doses  gradually  increased  to  twelve  or 
fifteen  grains  daily,  but  in  only  one  case  with  success.  In 
one  instance  it  was  replaced  by  the  infusion  of  bark  or  pepper- 
mint, without  any  advantage, 

493.  The  stomach  often  gave  indications  for  treatment. 
When  it  was  the  seat  of  acute  pains,  accompanied  by  heat, 
and  the  emaciation  and  debility  were  not  extreme,  leeches 
were  applied  to  the  epigastrium,  which  diminished  the  pains  for 
a  short  period,  but  they  returned  with  nausea  and  vomiting  of 
bile.    When  there  was  great  general  weakness,  emollient  drinks 


452  TREATMENT.  [Part  II, 

and  external  applications  were  the  only  remedies  entiployed  ; 
a  solution  of  gum  or  tartaric  syrup,  if  the  thirst  was  urgent  ; 
but  all  drinks  soon  inspired  disgust,  producing  a  sense  of 
weight  and  difficult  digestion  in  the  epigastrium.  The  Seltzer 
water  diluted  relieved  the  vomiting  for  some  days,  but  soon  lost 
its  effect.  Opium  neither  diminished  the  pain  nor  vomiting, 
which  arose,  as  we  have  seen  in  the  great  majority  of  instances, 
from  the  softening  and  thinning  of  the  gastric  mucous  mem- 
brane. 

494.  When  the  diarrliœa  was  slight,  the  food  was  simply 
diminished,  and  rice  water  with  gum  syrup  prescribed.  If  more 
urgent,  the  quince  syrup  was  substituted.  Under  this  treat- 
ment it  sometimes  remained  stationary,  or  was  even  suspend- 
ed, but  usually  it  increased,  and  then,  if  possible,  the  white 
decoction  and  the  diascordium,  either  with  or  without  opium, 
were  ordered,  but  in  general  unsuccessfully.  Twenty-five 
patients  were  submitted  to  this  treatment,  from  twelve  to 
forty-eight  days  before  death.  They  may  be  naturally  ranged 
into  three  classes  ;  in  some  there  were  ulcerations  in  one  or 
both  of  the  intestines,  generally  with  a  considerable  softening  of 
the  mucous  membrane  of  the  colon,  which  was  often  red  and 
thickened  ;  in  others  the  ulcerations  were  considerable,  and 
the  softening  of  the  lining  membrane  of  the  large  intestine  near- 
ly as  in  the  first  class  ;  in  a  third  class,  the  mucous  membrane 
was  simply  softened,  without  redness  or  ulceration.  In  the 
first,  including  fifteen  cases,  the  diarrhoea  was  diminished  in 
three  after  the  administration  of  the  diascordium,  and  continu- 
ed so  till  death  ;  in  one  of  these  instances  the  soilening  was 
inconsiderable.  In  the  second  division,  a  similar  result  was 
obtained  in  two  out  of  eight  individuals,  in  one  of  whom 
there  was  only  a  large  ulceration  in  the  cœcum.  Lastly,  in 
one   patient   of  the  third    class,    where    the   diarrhœa    was 


Chap.   12.]  TREATMENT.  453 

very  copious  before  taking  the  diascordium,  it  was  much 
diminished  from  the  moment  this  medicine  was  prescribed, 
and  continued  so  during  the  forty  days  preceding  death  ;  so 
that  out  of  twenty-five  cases,  six  only  appeared  to  have  been 
benefited  by  the  diascordium  ;  we  must  also  add  that  in 
three  instances  in  which  the  mucous  membrane  of  the  colon 
was  ulcerated,  softened,  or  thickened,  the  diarrhœa  was  in- 
creased by  the  diascordium. 

The  decoction  of  catechu  was  employed  with  the  same  in- 
tention, in  doses  of  four  to  eight  ounces.  Sixteen  patients  took 
it  ;  in  five  of  these  the  debility  was  too  great  and  death  too 
near  to  appreciate  the  action  of  medicine.  The  eleven  others 
began  its  use  from  two  to  three  v/eeks  before  death,  and  five 
appeared  benefited.  In  one  of  these,  however,  the  suppres- 
sion of  the  diarrhoea  was  immediately  succeeded  by  uneasi- 
ness, anxiety,  thirst,  heat  in  the  throat,  &,c.,  which  were 
worse  to  the  patient  than  the  diarrhoea.  After  death, we  found 
evident  traces  of  recent  inflammation  of  the  mucous  membrane 
of  the  stomach  and  trachea,  which  might  easily  in  this  instance, 
as  in  many  others,  have  been  spontaneous,  and  not  the  result 
of  the  remedy  employed  ;  there  were  also  numerous  intestinal 
ulcerations  with  softening  of  the  mucous  membrane  of  the 
colon.  These  last  lesions  were  equally  present  in  the  other 
cases.  Ratanhia  root  was  also  tried  in  the  same  circumstances 
in  one  case  without  success.  Lastly,  opium,  in  doses  of  one 
or  two  grains  a  day,  was  prescribed  in  five  cases,  but  the 
diarrhoea  diminished  in  only  one  instance. 

Thus  diascordium,  catechu,  opium  appeared  equal  in  their 
effects  upon  the  diarrhoea  of  the  advanced  stage  of  phthisis  ; 
and  from  the  difference  which  exists  in  the  action  of  catechu 
and  opium,  we  may  suspect  that  the  success  we  have  men- 
tioned is  rather  apparent  than  real. 


454  TREATMENT.  [Part  II. 

We'may  observe,  while  on  this  subject,  that  towards  the 
close  of  chronic  diseases,  and  particularly  of  phthisis,  it  would 
perhaps  be  preferable  to  avoid  any  stimulating  plan  in  the 
treatment  of  diarrhoea  ;  for,  from  the  facts  we  have  related  in 
the  first  part  of  this  volume,  diarrhœa,  in  the  majority  of  in- 
stances, is  dependant  upon  an  inflammatory  state  of  the  mu- 
cous membrane  of  the  large  intestine,  which  is  soon  followed 
by  disorganization  ;  and  as  this  membrane  is  the  principal 
source  of  the  diarrhœa,  our  remedies  should  be  chiefly  applied 
to  its  surface.  Let  us  add,  always  on  the  testimony  of  facts, 
that  the  last  period  of  chronic  disease  is  favorable  to  every 
kind  of  inflammation,  a  fact  which  should  constantly  be 
remembered,  whatever  class  of  symptoms  may  be  predomi- 
nant ;  also,  that  the  gastric  mucous  membrane  is  then  fre- 
quently affected,  an  additional  reason  to  employ,  in  general 
at  least,  mild  internal  remedies.* 

*  See  Translator's  Appendix,  H.  — H.  I.  B. 


APPENDIX. 


TRANSLATOR'S    APPENDIX. 


[It  is  proper  to  state  that  the  different  sections  of  this  Appendix  are  to  be 
found  in  various  parts  of  the  English  translation,  and  all  of  them  except  the 
first,  A,  are  printed  in  the  same  type  as  the  original.  It  is  true  that  the 
portions  thus  added  are  included  in  parentheses,  and  the  translator's  name  is 
attached  to  them,  but  when  several  pages  are  thus  introduced,  it  is  difficult 
for  the  reader  to  keep  carefully  in  mind  whether  he  is  reading  Louis's  de- 
ductions or  some  remarks  by  the  translator.  Wishing  that  the  original  work 
should  be  studied  without  any  extraneous  matter  to  divide  the  attention,  I  de- 
termined to  place  all  Dr.  Cowan's  additions  in  the  present  form.  They  con- 
tain some  very  valuable  data,  though  I  fear  he  has  quoted  at  times  from  some 
"  closet  therapeutic"  writings,  as  he  calls  them,  or^  in  other  words,  he  has 
cited  the  works  of  some  who  have  not  always  been  influenced  by  the  same 
philosophical  spirit  which  guided  Louis  in  his  investigations.  —  H.  I.  B.] 


A. 

Origin    and    development    of    Phthisis. 

We  have  no  intention  of  supplying  what  the  author  has  omitted,  by 
detailing  the  numerous  opinions  which  have  been  entertained  on  the 
origin  and  mode  of  development  of  tubercles.  We  refer  those  who 
are  desirous  of  pursuing  the  subject,  to  Dr.  Forbes's  Translation  of 
Laennec  ;  Bayle  (Recherches  sur  la  Phthisic  Pulmonaire)  ;  Andral 
[Precis.  Anat.  Pathol..^  and  his  Clinique  Médicale)  ;  Broussais  (Inflam- 
mations Chroniques,  vol.  i.)  ;  Cruveilhier  (Med.  Prat.  Eclairée  par 
J  3 


458         translator's  appendix. 

VJJnat.  Pathol.);  Lombard  (Essai  sur  les  Tuhercles)  ]  Magendie 
Jownal  de  Physiologie,  vol.  i.)  ;  Trousseau  and  Leblanc  (Archives 
Gen.  de  Med.,  1S28)  ;  and  in  our  own  country  to  the  writings  of  Drs. 
Alison,  Stokes,  Baron,  Williams,  Carswell,  Clark,  Spittall,  Rogers,  &.c. 
The  inquiry  has  elicited  more  talent  and  ingenuity  than  any  positive 
and  practical  results  :  we  would  therefore  warn  the  student  from  at- 
taching too  much  importance  to  the  subject,  and  recommend  him  to 
receive  all  opinions  and  hypotheses  with  great  reserve  and  caution. 
Let  him  remember,  that  since  tubercles  are  found  in  every  organ  of 
the  body,  all  opinions  relative  to  their  formation,  which  are  depend- 
ing on  the  peculiar  structure  of  the  lungs,  are  necessarily  capable  of 
only  partial  application,  while  analogy  would  lead  us  to  suppose  that 
an  identical  morbid  production,  so  generally  distributed,  would  origi- 
nate in  some  tissue  common  to  all  our  organs. 

The  form  and  rapidity  of  tuberculous  deposition  are  undoubtedly 
subject  to  great  variations  ;  these  difierences  are  most  sensible  in  a 
comparative  view  of  tubercles  in  the  lungs  and  those  in  other  organs, 
though  in  many  cases  of  acute  phthisis  the  formation  of  pulmonary 
tubercles  seems  free  from  any  peculiarities  ;  and,  on  the  other  hand, 
the  previous  modifications  to  their  complete  development,  which  are 
in  general  only  to  be  traced  in  the  lungs,  are  occasionally  present  in 
other  organs  ;  these  facts  may  explain  many  variations  in  the  progress 
of  phthisis,  and  show  how  very  opposite  opinions  may  be  equally  true, 
in  particular  circumstances,  while  they  are  all  false  in  any  general 
application. 

As  the  relative  frequency  of  tubercles  in  our  different  organs  is  a 
very  important  question  in  the  history  of  phthisis,  we  shall  compare 
our  author's  results  with  those  of  other  observers,  remarking  that 
they  are  not  to  be  regarded  as  definitive,  but  merely  as  incentives  to 
further  investigations.  Laennec,  in  his  section,  "  Organic  Changes 
which  usually  attend  phthisis"  (page  28fi),  while  he  agrees  in  most 
points  with  M.  Louis,  has  not  reduced  his  observations  to  the  numeri- 
cal form,  and  has  evidently  allowed  the  condition  of  the  pulmonary 
organs  almost  wholly  to  engross  his  attention.  Andral  principally 
differs  from  M.  Louis  in  having  found  rather  more  frequently  tuber- 
cles in  various  organs  when  none  existed  in  the  lungs  ;  he  also  thinks 
them  more  frequent  in  the  pleural  and  peritoneal  false  membranes, 


ORIGIN    AND    DEVELOPMENT    OF    PHTHISIS.  459 

testicles  and  bones.  M.  Lombard,  in  his  Essai  sur  les  Tubercles,  in 
100  adult  plithisicai  patients,  found  tubercles  in  the  intestines  26 
times  ;  in  the  mesenteric  glands,  19  ;  bronchial  glands,  9  ;  cervical, 
7  ;  spleen,  6  ;  lumbar  glands  and  the  sub-peritoneal  cellular  tissue, 
4  ;  axillary  glands  and  anterior  mediastinum,  3  ;  subarachnoidean 
cellular  tissue,  spinal  marrow,  false  membranes  of  the  pleurse  and 
peritoneum,  intercostal  muscles  and  ovaries,  2  each  ;  gall-bladder, 
liver,  posterior  mediastinum,  pleura,  vertebrse,  omentum,  uterus,  pros- 
tate, bladder,  cerebrum  and  cerebellum,  medulla  oblongata,  kidneys, 
and  vesiculfe  séminales,  1  each. 

The  same  observer,  in  100  cases  of  phthisis  in  infants,  gives  the 
following  proportions  :  —  Bronchial  glands,  87  ;  lungs,  73  (30  times 
in  only  one  lung,  13  in  the  left,  17  in  the  right)  ;  mesenteric  glands, 
31  ;  spleen,  25  ;  kidneys,  11  ;  intestines,  9  ;  brain,  9  ;  cervical  glands 
7^  meningœal  membranes,  6  ;  pancreas^  gastro-hepatic  glands,  cel- 
lular tissue  lining  the  peritoneum,  5  ;  spleen  4  or  25  (this  organ  is 
twice  mentioned,  with  two  widely  different  numbers,  —  the  result 
had  better  be  considered  negative)  ;  inguinal  glands,  3  ;  cellular  tis- 
sue lining  the  pleurœ,  2  ;  lumbar  glands,  bladder,  omentum,  gall- 
bladder and  false  membranes  covering  tlie  pleura,  ]  each.  Though 
these  figures  may  not  be,  and  probably  are  not,  rigorously  exact,  yet 
the  variations  in  the  frequency  of  tubercles  in  the  different  organs  in 
the  adult  and  infant  are  most  striking  and  too  considerable  to  depend 
on  any  accidental  inaccuracies. 

The  more  frequent  occurrence  of  tubercles  in  the  bronchial  glands 
than  in  the  lungs,  (Andral  has  observed  this  fact  in  the  adult,  but 
very  rarely,  —  Vide  Clinique  Médicale,  Maladies  de  Poitrine),  in  the 
mesenteric  glands  than  in  the  intestines,  and  the  inverse  proportion 
in  the  lungs  and  in  the  cervical  glands,  is  remarkable  and  rather 
difficult  to  explain  by  the  doctrine  of  irritation  of  the  mucous  mem- 
branes. The  preponderance  of  tubercles  in  the  brain,  and  meninges 
in  infants  is  also  striking,  and  coincides  with  general  observation. 
M.  Lombard  seems  to  have  omitted  altogether  the  pharynx,  larynx 
and  trachea. 

We  may  then  conclude  that  in  children  the  distribution  of  tuber- 
cles differs  widely  from  that  in  adults,  that  they  exist  in  a  greater 
number  of  organs  at  once,  and  are  not  so  invariably  present  in  the 


460  translator's  appendix. 

lungs.  We  are  disposed  to  think  that  the  latter  fact  is  not  satisfac- 
torily established,  either  for  infants  or  adults,  and  that  the  value  of 
M.  Louis's  observations  on  this  point  (which  only  present  one  excep- 
tion in  350  examples)  is  not  yet  impaired,  for  we  must  remember 
that  MM.  Andral  and  Lombard,  not  considering  the  grey,  semi-trans- 
parent granulations  to  be  a  modification  of  tubercles,  they  no  doubt 
have  omitted  to  mention  them  in  their  calculation,  and  this  may  be 
the  cause  of  the  non-accordance  of  their  results  with  those  of  M. 
Louis. 

Tubercles  are  not  peculiar  to  man,  they  are  very  frequently  found 
in  horses,  and  appear  in  these  animals  to  be  more  frequent  in  the 
fibro-cellular  tissue  of  the  nasal  fossae,  than  in  the  lungs.  —  (Vide  M. 
Dupuy,  De  V Affection  Tuberculeuse,  &fc.,  8vo.  J  817.  Paris).  They 
are  rare  in  the  intestines,  M.  Dupuy  only  finding  them  twice  out  of 
seventy-two  cases.  The  same  observer  has  found  them  in  the  pig  5 
and  here  they  are  in  general  associated  with  the  cysticercus.  In 
monkeys,  various  rodentia,  and  in  cows  they  frequently  abound  ;  and 
in  all  occupy  a  variety  of  organs. — (Vide  Andral,  Precis,  de  Anatomie 
Pathologique,  page  431,  vol.  i.)  In  the  twenty-second  number  of  the 
Annales  d'Hygiène  Publique,  there  is  a  letter  from  M.  Huzard,  on  the 
liability  of  cows,  confined  in  the  stables  of  Paris,  to  consumption. 
The  author  simply  establishes  the  fact,  that  they  are  very  liable  to  the 
disease,  but  has  not  analyzed  the  various  influences  to  which  they  are 
exposed,  in  a  way  calculated  to  admit  of  any  positive  and  satisfactory 
inductions. 


B. 

Diagnosis    of    Phthisis. 

We  have  already  directed  the  reader's  attention  to  the  study  of 
the  expiration,  as  an  additional  means  of  detecting  an  alteration  in 
the  density  of  the  lung,  and  insisted  upon  its  importance  as  peculiarly 
applicable  to  the  earlier  periods  of  tubercular  deposition.  The  differ- 
ence in  the  seat  of  simple  bronchitis  and  of  that  which  is  complicated 


DIAGNOSIS    OF    PHTHISIS.  461 

with  pulmonary  tubercles,  is  a  fact  not  less  remarkable  than  impor- 
tant in  aiding  our  diagnosis  of  phthisis,  and  has  never  yet  received 
that  attention  which,  judging  from  the  evidence  of  M.  Louis,  it  un- 
doubtedly deserves.  He  has  invariably  found  that  the  sibilant, 
mucous  and  submucous  râles,  resulting  from  simple  catarrh,  originate 
in  the  loioer  part  of  the  chest,  while  bronchitis  complicated  with  pul- 
monary tubercles,  is  always  situated  in  the  tipper  lobes.  Simple  bron- 
chitis usually  attacks  both  sides  of  the  chest,  while  the  rhonchus  from 
tubercles  is  at  first  almost  constantly  confined  to  the  upper  lobe  of 
one  side.  In  the  eruptive  diseases,  continued  fever  and  emphysema, 
the  seat  of  the  bronchial  inflammation  is  constantly  in  the  lower  lobe  ; 
and  during  the  last  three  years,  out  of  more  than  140  cases,  M.Louis 
has  not  met  with  a  single  example  in  contradiction  of  the  above  state- 
ment. When  bronchitis  is  universal,  of  course  these  distinctions  are 
not  available,  unless  we  have  been  enabled  to  follow  its  gradual  pro- 
gress. Of  the  immense  importance  of  this  law,  there  can  only  be 
one  opinion  ;  and  in  many  instances  attention  to  the  seat  of  bronchitis 
would  dissipate  much  doubt  and  anxiety,  and  early  indicate  the  real 
nature  of  an  affection  which,  without  the  knowledge  of  this  fact, 
would  frequently  be  confounded  with  simple  catarrh,  and  thus  frus- 
trate the  hopes  both  of  the  patient  and  practitioner. 

There  are  some  rare  instances  of  chronic  bronchitis  with  dilatation 
of  the  bronchia  in  the  upper  lobes  (Obs.  II),  which  might  easily, 
judging  simply  from  some  local  symptoms,  such  as  pectoriloquy  and 
gargouillement,  be  mistaken  for  tuberculous  excavations.  Under 
these  circumstances  we  must  carefully  inquire  into  the  history  of  the 
case,  the  duration  of  the  symptoms,  their  being  limited  to  one  side  of 
the  chest,  the  absence  of  fever,  and  the  preceding  characters  of  the 
bronchial  affections  to  which  the  patient  has  been  liable.  The  pres- 
ence also  of  haemoptysis,  pains,  and  especially  the  condition  of  the 
digestive  tube,  would  perhaps  always  enable  us  to  arrive  at  some  satis- 
factory distinguishing  characters  between  these  two  affections.  Per- 
cussion also  would  assist,  for  around  chronic  tuberculous  excavations» 
more  or  less  sensible  induration  of  the  lung  would  have  occurred  ; 
and  this  is  not  usually  the  case  for  dilated  bronchia.  In  those  in- 
stances where  the  size  of  the  tubercular  cavity  renders  percussion 
clear,  notwithstanding   the  partial  induration,  it  would  be  scarcely 


462  translator's  appendix. 

possible  to  confound  the  acoustic  phenomena  with  those  arising  from 
dilated  bronchia.  "• 

Tho  situation  and  character  of  pneumonia  may  also  aid  our  diag. 
nosis  of  tubercles.  In  the  great  majority  of  cases  amono-  young  sub- 
jects it  is  seated  in  the  loiver  lobe,  and  is  usually  confined  to  one  side 
of  the  chest  ;  while  in  persons  above  fifty  M.  Louis  has  found  that 
the  uppe7'  lobe  is  more  frequently  affected.  An  attack  of  double  pneu- 
monia  in  the  upper  lobes  is  a  very  probable  indication  of  tubercles. 
These  remarks  are  not  applicable  to  the  pneumonia  which  so  often 
occurs  towards  the  close  of  life  ;  it  then  not  unfrequently  occupies 
both  sides  of  the  chest. 

It  may  be  worth  observing",  that  in  measles  the  expectoration  is 
often  nummulated  and  flocculent,  as  in  the  second  stage  of  phthisis. 
We  may  also  again  advert  to  the  fact,  that  the  existence  of  chronic 
peritonitis  is  sufficient  to  justify  the  diagnosis  of  pulmonary  tubercles 
though  no  general  symptoms  may  have  directed  our  attention  to  the 
iungs.  In  the  chapters  on  latent  and  acute  phthisis,  the  reader  will 
be  enabled  to  appreciate  some  of  those  numerous  difficulties  which 
often  interfere  with  the  diagnosis  of  phthisis,  and  at  the  same  time 
be  convinced  how  variable  are  the  symptoms,  and  incalculable  the 
progress  of  this  affection.  The  absence  of  cough  and  of  expectoration 
at  a  time  when  tubercular  cavities  are  present  in  the  lung,  the  vio- 
lence of  the  general  symptoms  while  the  lesion  of  the  pulmonary 
organs  is  barely  to  be  detected  by  the  most  careful  examination,  are 
facts  never  to  be  lost  sight  of,  and  highly  calculated  to  prevent  hasty 
conclusions  respecting  the  presence  or  absence  of  a  disease,  which, 
•while  rarely  or  ever  destitute  of  some  local  characteristics,  is  often  so 
protean  in  its  general  manifestations.  The  student's  attention  is  too 
apt  to  be  directed  to  the  signs  of  phthisis  in  its  advanced  stage,  such 
as  pectoriloquy  and  purulent  expectoration,  &c.  &c.  ;  but  these  prom- 
inent symptoms  are  certainly  of  secondary  interest  to  those  numerous 
and  earlier  indications  gathered  from  an  accurate  history  of  the  case, 
from  a  correct  investigation  of  the  succession  of  the  symptoms,  and 
from  the  knowledge  of  their  individual  value.  The  appreciation  of 
the  nicer  shades  of  auscultation  and  percussion  can  only  be  acquired 
by  long  and  persevering  practice  ;  but  the  affirmative  and  negative 
value  of  the  evidence  which  this  means  of  examination  affords,  will 


DIAGNOSIS    OF    PHTHISIS.  463 

amply  repay  the  time  and  trouble  expended  in  obtaining  the  neces- 
sary skill  for  its  acquirement.  It  is  far  more  practically  useful  to 
detect  the  first  indications  of  tubercular  deposition,  than  accurately 
to  describe  the  varying  and  curious  acoustic  phenomena  resulting 
from  an  excavation  in  the  lungs;  far  more  useful  to  be  able  rightly 
to  interpret  the  value  of  the  white  frothy  expectoration,  than  to  mul- 
tiply experiments  for  the  purpose  of  discovering  the  presence  of  pus. 
Let  it  be  remembered  that  there  is  no  one  symptom  which  constitutes 
a  disease,  nor  any  one  phenomenon  which  is  invariably  present  ;  our 
diagnosis  to  be  correct,  must  be  deduced  from  all  the  symptoms 
which  are  submitted  to  our  notice,  and  their  just  estimation,  founded 
upon  an  accurate  knowledge  of  the  pathology  of  the  affection. 

The  habit  of  mingling  the  description  of  all  the  accessory  symp- 
toms with  those  which  are  the  fundamental  signs,  has  been  most 
injurious  to  the  progress  of  diagnosis,  and  in  the  indiscriminate  enu- 
meration of  every  possible  variation  which  may  be  noticed  in  the 
progress  and  symptoms  of  any  disease  when  associated  with  indi- 
vidual peculiarities,  the  essential  and  leading  features  are  too  apt  to 
be  overlooked,  and  no  definite  or  satisfactory  information  conveyed 
to  the  mind.  The  uncertainty  almost  constantly  attending  the  just 
appreciation  of  particular  symptoms,  which  we  well  know  may  depend 
on  very  different  and  opposite  causes,  gives  great  additional  value  to 
every  increase  of  our  facilities  for  the  physical  examination  of  our 
organs.  The  results  which  this  method  of  investigation  affords,  are 
not  exposed  to  the  same  liability  to  error,  and  though  frequently  in- 
capable of  affording  any  elucidation  as  to  the  nature  or  seat  of  par- 
ticular diseases,  they  always  possess  a  negative  value  of  no  small 
importance  to  the  practitioner,  both  as  to  prognosis  and  treat- 
ment. Let  the  student  also  recollect  that  he  cannot  be  too  mi- 
nute in  his  inquiries: — accurate  diagnosis  is  founded  upon  minutiae, 
and  it  is  only  by  multiplying  our  points  of  recognition,  that  we  can 
trace  with  any  certainty  the  ever-varying  features  of  disease.  We 
at  the  same  time  improve  our  own  sagacity,  and  acquire  that  perspi- 
cuity in  description  by  which  our  observations  become  available  to 
others  ;  the  mind  no  longer  rests  satisfied  with  some  shadowy  and 
uncertain  conclusions,  but  by  patient  and  minute  investigation  seeks 
to  combine  and  rationalize  the  often  complicated  materials  from  which 


464  translator's  appendix. 

remedial  indications  are  to  emanate.  The  want  of  correct  diagnosis 
has  been  peculiarly  evident  on  the  subject  of  phthisis,  and  has  ren- 
dered useless  a  vast  mass  of  information  on  the  therapeutics  of  this 
disease,  because  in  many  cases  the  existence  of  the  disease  itself 
may  be  questioned.  At  no  period  of  medicine  has  diagnosis  been  so 
generally  or  successfully  studied  as  at  present,  but  at  the  same  time  we 
feel  that  it  is  far  from  being  cultivated  so  extensively  as  it  deserves, 
and  we  sincerely  trust  that  the  younger  branches  of  the  profession 
will  make  it  still  more  an  object  of  special  study  and  devotion. 


c. 


Influence     op     Sex    in     the      production     of 
Phthisis. 

M.  Benoiston  de  Chateauneuf,  in  a  very  interesting  memoir  to 
which  we  have  more  particularly  referred  in  the  notes  to  this  chapter, 
says,  that  out  of  1554  deaths  from  phthisis,  745  were  men,  809  women. 
In  the  Statistical  Tables  of  Paris,  published  under  the  auspices  of  M. 
Chabrol  (Vide  Journ.  des  Progrés  des  Sciences  et  des  Inst.  Médicales, 
t.  ii.  1830),  we  find  that  out  of  9542  cases  of  phthisis,  5582  were 
women,  3960  men.  M.  Lepelletier  found  that  the  number  of  phthisi- 
cal females  admitted  into  the  hospitals  of  Paris,  were  in  relation  to 
males  as  5  to  3.  Dr.  Papavoine,  in  his  Inaugural  Essay  on  Tuber- 
cles, mentions  that  out  of  532  girls  from  the  age  of  2  years  to  15,  ex- 
amined at  the  hôpital  des  Enfans  Malades,  308,  or  two  thirds,  were 
tuberculous  ;  while  out  of  388  boys,  210,  or  about  a  similar  propor- 
tion, presented  the  same  morbid  peculiarity.  Dr.  Darwall,  in  his 
summary  of  cases  at  the  Birmingham  dispensary  (Vide  Midland  Med. 
and  Surg.  Reporter,  No.  3,  Feb.  1829),  gives  8G  cases  of  tubercular 
consumption,  48  of  which  were  women,  38  men.  To  this  evidence 
we  might  add  the  opinions  of  a  variety  of  authors,  both  ancient  and 
modern,  in  favor  of  the  greater  liability  of  women  to  this  disease,  but 
we  shall  confine  ourselves  to  numerical  results,  and  we  think  the 


INFLUENCE  OF  SEX  IN  THE  PKODUCTION   OF  PHTHISIS.    465 

Striking  accordance  of  the  above  sufficient  to  establish  the  fact  in 
question.  It  may  be  objected  that  they  were  not  all  cases  of  phthisis  ; 
probably  not,  but  since  the  majority  of  fatal  pulmonary  cases  are 
phthisical,  and  as  the  relative  frequency  of  pleurisy  and  pneumonia 
in  either  sex  is  the  inverse  of  that  of  phthisis,  this  objection  tends  to 
strengthen  rather  than  invalidate  the  results.  The  proportions  given 
by  Dr.  Papavoine  respecting  children,  in  whom  sex  seems  to  have  no 
influence,  are  rather  confirmative  than  contradictory,  for  at  this  period 
of  life  the  peculiarities  of  either  sex  are  not  developed,  and  their 
habits,  among  children  of  the  lower  classes  at  least,  do  not  essen- 
tially vary.  If  dress,  professions,  and  sedentary  occupations  are  the 
causes  of  phthisis  in  the  adult,  we  might  have  expected  à  priori,  that 
the  relative  frequency  of  the  disease  would  only  be  apparent  Avhen 
these  causes  become  active.  It  must  not  be  forgotten  that  these 
results  are  principally  derived  from  the  Statistical  Tables  of  Paris, 
and  are  not  in  unison  with  those  obtained  in  New  York,  Sweden,  &c. 
(Vide  Cyclop.  Pract.  Med.,  part  xxii.  page  309).  They  cannot,  there- 
fore,, be  regarded  as  more  than  a  highly  probable  approximation  to 
the  truth,  founded  upon  the  greater  comparative  accuracy  of  the  de- 
tails, and  their  being  collected  at  a  time  when  the  knowledge  of  the 
diagnosis  of  phthisis  and  post-mortem  examinations  gave  a  previously 
unknown  value  to  all  researches  upon  this  subject.  To  arrive,  how- 
ever, at  positive  conclusions,  it  would  be  necessary,  as  Dr.  Clarke 
says,  to  know  the  relative  number  of  the  sexes  alive  in  each 
place,  their  relative  deaths  from  other  diseases,  and  their  relative  ad- 
missions into  the  hospitals  referred  to.  The  habits  and  occupations 
of  the  sexes,  the  district  being  manufacturing  or  otherwise,  would  no 
doubt  produce  many  local  modifications  in  the  results. 


K    3 


466 


TRANSLATOR  s    APPENDIX. 


D. 


Influence    of    Pneumonia   in    the    production 
OF    Phthisis. 

M.  Lombard,  in  a  valuable  memoir  on  the  respective  prevalence  of 
pneumonia  in  either  side  of  the  chest  (Vide  Jlrch.  Gen.  de  Med.,  Jan. 
1831),  says  that  in  968  cases  collected  by  Andral,  Chomel  and  him- 
self, 195  had  pneumonia  in  both  lungs,  260  in  the  left  lung,  413  in  the 
right.  This  is  strong  additional  evidence  in  favor  of  M.  Louis's 
results  ;  it  is  to  be  regretted  that  in  195  cases  of  double  pneumonia, 
the  presence  or  absence  of  tubercular  complication  is  not  mentioned* 
The  same  author  has  investigated  the  influence  of  age  on  pneu- 
monia. His  researches  are  founded  on  206  children  from  the  age  of 
1  day  to  J  8  months,  on  118  from  18  months  to  14  years,  and  on 
1284  persons  of  ages  varying  from  15  to  83.  He  infers  that  pneu- 
monia forms  three  seventeenths  of  all  the  organic  derangements 
found  in  infants  who  have  died  during  the  first  eight  days  ;  two  ninths 
during  the  second  week  ;  three  tenths  during  the  third  week  ;  two 
ninths  between  the  sixth  week  and  end  of  the  eighth;  one  tenth  only 
between  the  second  and  sixth  month.  In  the  second  year  it  amounts 
to  one  third  ;  from  the  second  year  to  the  sixth,  one  fourth  to  one 
fifth  ;  from  the  eighth  to  the  eleventh,  one  fourth  to  one  sixth  ;  from 
the  fourteenth  to  the  nineteenth  only  one  thirty-seventh  ;  from  the 
nineteenth  to  the  twenty-seventh,  one  ninth  ;  from  the  twenty- 
seventh  to  the  forty -seventh,  one  fifteenth;  from  the  forty-seventh 
to  the  eighty  fifth,  one  fourteenth;  above  this,  one  eighth.  The 
reader  is  requested  to  compare  these  results  with  similar  researches 
in  phthisis,  and  he  will  find  them  corroborate  the  author's  opinion,  as 
to  tlie  independence  of  pneumonia  and  tubercles  ;  indeed  we  think 
that  an  impartial  view  of  all  the  preceding  facts  renders  this  con- 
clusion inevitable.  It  may  not  be  uninteresting  to  oppose  the  testi- 
mony of  facta  to  the  propositions  (163 — 171)  of  M.  Broussais.  Baylo, 
Laennec,  Andral,  Lombard,  all  agree  in  regarding  pneumonia  as  a 
very  secondary  cause  of  phthisis. 


INFLUENCE  OF  BHONCHÏTIS   IN  PRODUCING  PHTHISIS.    467 


E. 


Influence  of  Bronchitis  in   the  production 
OF    Phthisis. 

This  section  (478)  and  the  authors  reasoning  are  particularly  worthy 
of  serious  attention,  and  highly  calculated  to  shake  our  faith  in  some 
of  apparently  the  best  substantiated  medical  facts.     Perhaps  in  the 
history  of  phthisis   no  one  opinion   was   more   universally  admitted, 
than  that  bronchitis  was  amongst  the  most  frequent  and  active  causes 
of  pulmonary  tubercles  ;  this  cannot  however  be  any  longer  supported 
and  its  accuracy  is  rendered   still  more  problematical   by  what  has 
been  advanced  in  the  notes  on  "  Diagnosis,"  as  to  the  situation  of 
simple  bronchitis  at  the  hase  of  the  lungs.     Chronic  inflammation  of 
the  bronchial  mucous   membrane   does  not  appear  more  influential. 
In  eleven  cases  of  dilated  bronchia,  where  the  general  symptoms  of 
phthisis  had  not  been  present,  and  the  duration  of  the  affection  was 
from  two  to  six  years,  the   raucous   membrane   was  intensely  red, 
thickened  and  granulated,  while  tubercles  existed  only  in  three,  and 
were  neither  numerous  nor  softened.     It  is  not  intended  to  deny  that 
bronchitis   may  and   does   occasionally  hasten   the   development   of 
tubercles  (acting  like  all  other  causes  which  tend  to  weaken  the  sum 
total  of  health),  but  that  it  has  no  direct  specific  influence.     Indeed  we 
may  perhaps  conclude,   that  any  source  of  intense   and  prolonged 
febrile  movement  may  be  indirectly  the  cause   of  tubercles.     Out  of 
forty-six  cases  of  continued  fever  (affection  typhoide)  observed  by  M. 
Louis,  m  four  there  were  some  tubercles   or  grey,  semi-transparent 
granulations  in  the  summit  of  the  lungs,  and  in  these  instances  death 
took  place  from  the  twenty-fifth  to  the  forty-sixth  day  of  the  disease. 
No  tubercles  were  found  in  those  Avho  died  at  an  earlier  period. — 
(Vide  An.  d'Hyg.  Pub.,  No.  11,  page  55.) 

Simple  increased  circulation,  when  not  inflammatory,  cannot  be 
regarded  as  a  cause  of  tubercles.  M.  Louis  has  collected  forty-four 
fatal  cases  of  diseases  of  the  heart;  nineteen  were  hypertropliy  of 


468  translator's  appendix. 

the  right  auricle,  twenty-nine  hypertrophy  of  the  right  ventricle. 
In  six  of  the  latter  the  pulmonary  artery  was  enlarged  and  thickened, 
thus  proving  the  increased  impetus  of  the  circulation:  —  in  all  there 
were  only  two  examples  of  pulmonary  tubercles,  while  in  fifty  cases 
of  cancer  this  complication  existed  in  eleven  instances.  To  conclude 
this  irresistible  mass  of  evidence,  in  forty  cases  of  emphysema  of  the 
lungs,  accompanied  with  chronic  bronchitis  of  several  years  duration, 
only  four  presented  tubercles  in  the  lungs;,  and  in  one  alone  were 
they  numerous.  —  (Vide  Examen,  page  78.) 


F. 


Influence    of    Dress  in    the    production    of 
Phthisis. 

We  cannot  coincide  with  the  author's  reasoning  in  this  paragraph 
(479).  The  fact  of  stays  only  being  worn  after  the  chest  was  fully  devel- 
oped does  not  in  the  least  weaken  the  evidence  of  their  being  a  cause 
of  phthisis,  for  the  respiratory  and  digestive  functions  may  be  equally 
impeded  by  any  obstructions  to  the  movements  of  the  thorax  as  by 
those  which  influence  its  development.  The  change  of  habits  also 
in  the  individuals  mentioned,  from  a  country  life  to  a  residence  in 
Paris,  renders  all  calculations  on  the  influence  of  dress  valueless. 
From  the  evidence  brought  forward  at  the  end  of  this  chapter  (G),  rela- 
tive to  certain  professions,  it  may  be  fairly  argued,  in  the  absence  of 
any  positive  evidence  on  the  influence  of  particular  articles  of  dress, 
which,  as  the  author  says,  it  would  be  very  difficult  to  obtain,  that  what- 
ever interferes  with  the  free  action  of  the  lungs,  either  by  any  habit- 
ual posture  of  the  body,  or  mechanical  obstruction,  may  be  considered 
as  powerfully  predisposing  to  pulmonary  tubercles.  In  delicate 
children  particularly,  the  effect  of  any  mode  of  dress  by  which  mus- 
cular action  is  impeded  cannot  but  be  most  prejudicial,  and  if  not 
terminating  in  phthisis,  is  undoubtedly  the  most  fruitful  source  of 
spinal  deformity. 


INFLUENCE    OF    AGE. 


469 


G. 


Influence    of    various    causes    in    the    pro- 
BUCTioN    OF    Phthisis. 

These  results  (481),  are  confirmed  by  those  of  Dr.  Darwall;  in 
forty-eight  female  cases  of  phthisis,  the  numbers  were  as  follows  :  — 

Deaths. 

9 

16 

16 

6 

1 

In  the  Statistical  Tables  of  Paris  already  referred  to  (C),  founded 
on  9542  examples  of  phthisis,  we  find  ages  arranged  according  to  the 
relative  frequency  of  tubercles. 


Age. 

15  to 

20 

20  to 

30 

30  to 

40 

40  to 

50 

55 

20  to  30 
SO  to  40 
10  to  20 
40  to  50 
50  to  60 


Age. 

0  to  10 
60  to  70 
70  to  80 
80  to  90 
90  to  100 


This  table  strengthens  the  preceding  with  regard  to  the  adult  age  ; 
for  the  earlier  periods  of  life,  the  materials  are  less  copious  and  from 
many  circumstances  less  likely  to  be  correct.  Of  this  Ave  may  judge 
by  comparing  the  recent  researches  of  Drs.  Lombard  and  Papavoine, 
made  at  the  Hôpital  des  Enfans  Malades.  The  former  has  found 
tubercles  in  one  eighth  of  the  children  who  die  between  their  first 
and  second  years  ;  in  two  sevenths  between  the  second  and  third 
years  ;  in  four  sevenths,  between  the  third  and  fourth  ;  in  three  fourths, 
between  the  fourth  and  fifth  years.  From  this  last  period  until 
puberty,  tubercles  are  more  frequent  than  anteriorly  to  the  fourth 
year,  but  less  so  than  between  the  ages  of  four  and  five.    These  results 


470 


TRANSLATOR  S    APPENDIX. 


are  very  similar  to  those  of  Dr.  Papavoine  ;  this  pathologist  has  found 
that  from  the  fourth  to  the  fourteenth  year  the  number  of  tuberculous 
children  is  greater  than  that  of  those  who  are  not  so  ;  that  tubercles  are 
most  frequent  betAveen  the  fourth  and  seventh  years  ;  that  they  again 
become  numerous  from  the  twelfth  to  the  thirteenth  year  ;  that  be' 
tween  the  fourteanth  and  fifteenth  years  the  same  proportions  exist 
as  between  the  third  and  fourth.  These  data  are  founded  on  the  post- 
mortems of  920  children  (388  boys — 532  girls),  from  the  age  of  two 
years  to  fifteen.  Out  of  these  538,  or  nearly  three  fifths,  presented 
tubercles. — (Vide  Journ.  des  Prog,  des  Se.  Médicales,  t.  ii.  1830  :  and 
Revue  Med.,  June,  1830).  The  above  details  all  coincide  in  placing 
the  maximum  of  tubercles  in  the  adult,  between  the  ages  of  twenty 
and  forty.  The  great  frequency  of  tubercles  in  children  as  implied 
by  the  researches  of  Drs.  Lombard,  Papavoine  and  others,  is  a  fact 
of  considerable  interest,  and  is  not  consonant  with  what  has  hitherto 
been  the  general  opinion.  This  no  doubt  may  be  attributed  prin- 
cipally to  our  pathology  being  now  founded  on  post-mortem  exami- 
nations, and  not  on  mere  symptomatology  ;  also  to  the  modifications 
which  age  produces  in  the  symptoms  of  tubercles,  to  their  different 
distribution  in  children,  and  their  frequent  manifestation  by  abdomi- 
nal rather  than  thoracic  symptoms.  The  question  of  the  influence  of 
age  is  an  important  one,  and  is  still  depending  on  future  investiga- 
tions for  its  complete  elucidation.  We  refer  the  reader  to  the  able 
summary  of  Dr.  Clarke  (Vide  Cyclop,  of  Pract.  Med.  part  xxii.  page 
307),  for  more  extended  details  on  this  interesting  subject. 

The  causes  of  phtliisis  have  never  received  that  attention  which 
they  really  deserve,  more  especially  since  the  result  of  their  influ- 
ence is  a  morbid  condition  of  the  system,  for  the  removal  of  which, 
medicine  has  hitherto  been  almost  inert.  Under  tliese  circumstances 
prevention  is  evidently  a  more  important  investigation  than  cure,  and 
the  active  agents  of  tubercular  disease  merit  our  most  serious  and 
attentive  research.  There  is  one  prevailing  error  which  has  attended 
the  majority  of  investigations  on  the  etiology  of  this  and  other  dis- 
eases, which,  in  the  appreciation  of  the  succeeding  remarks,  must 
not  be  forgotten.  Every  possible  influence  has  been  occasionally 
associated  with  an  affection  so  frequent  in  its  occurrence,  and  the 


INFLUENCE    OF    VARIOUS    CIRCUMSTANCES.  471 

long  list  of  causes  often  contains  an  indiscriminate  enumsKation  of 
every  agent  capable  of  modifying  the  health,  without  any  definition 
of  its  relative  activity,  or  any  attempt  to  distinguish  between  M'hat 
essentially  predisposes  to  disease  and  what  simply  hastens  its  devel- 
opment after  the  predisposition  has  been  formed.  Without  attention 
to  this  the  causes  of  disease  can  never  be  classified,  for  in  proportion 
as  the  health  is  debilitated  and  constitutional  peculiarities  abound, 
do  we  multiply  the  number  and  activity  of  those  influences  which  re- 
act upon  the  frame,  and  thus  each  individual  adds  a  new  cause  to  our 
list,  until  novelty  is  almost  impossible,  and  prophylactic  treatment 
would  require  another  Avorld  for  its  employment.  In  attempting, 
therefore,  to  investigate  the  causes  of  consumption,  those  influ- 
ences are  alone  examined  which  appear  capable,  by  a  more  or  less 
prolonged  application,  of  producing  tubercular  deposition  in  a.  healthy 
individual.  In  accordance  with  these  views,  we  shall  now  make  the 
reader  acquainted  with  some  recent  extensive  researches  on  this 
most  important  subject. 

It  will  be  necessary  almost  entirely  to  confine  our  remarks  to  the 
conclusions  admitted  by  all,  or  by  the  majority  of  those  on  whose  in- 
quiries we  can  rely,  for  each  author  having  adopted  a  different  plan 
in  the  arrangement  of  his  details,  and  arrived  at  different  results  with 
regard  to  many  individual  facts,  it  would  require  a  volume  rather  than 
a  note  to  enter  at  length  into  those  considerations  by  which  these 
differences  might  either  be  explained,  or  attributed  to  the  peculiar 
and  à  priori  views  of  the  nature  and  causes  of  phthisis,  which  have 
occasionally  influenced  the  writers.  Our  principal  sources  of  infor- 
mation are  three. 

1st.  A  memoir,  by  M.  Benoiston  de  Chateauneuf,  on  the  relations 
of  consumption  to  trades  and  professions  generally,  published  in  the 
Annales  d'Hyg.  Puhl.  for  July,  1831.  It  is  founded  upon  the  inspec- 
tion of  the  registers  of  four  of  the  principal  hospitals  of  Paris,  inclu- 
ding a  period  of  five  or  ten  years,  as  the  individuals  belonging  to 
particular  professions  were  numerous  or  otherwise,  determining  the 
proportion  which  the  deaths  from  phthisis  in  each  trade  bear  to  the 
total  admissions  of  persons  of  that  trade.  The  number  of  professions 
(principally  among  the  operative  classes),  is  42,  and  the  sum  total  of 
admissions  43,000  (26,045  men   and  16,955  women).     Out  of  these 


472  translator's  appendix. 

1554  have  died  from  thoracic  affections,  (745  men,  809  women),  or 
ahout  one  thirty-fifth  for  the  former  and  one  twenty-first  for  the 
latter.  The  reader  will  at  once  perceive  that  this  mode  of  deciding 
the  question  can  never  be  completely  satisfactory,  for  the  determi- 
nation of  the  comparative  mortality  of  phthisis  in  any  particular  pro- 
fession requires  a  knowledge  of  the  number  of  deaths  in  that  pro- 
fession from  diseases  in  general.  We  might,  without  this  information, 
discover  that  phthisis  was  more  or  less  frequent  in  certain  circum- 
stances, but  the  peculiar  tendency  to  its  production  rather  than  other 
diseases,  can  only  be  resolved  by  the  comparison  to  which  we  have 
alluded.  This  has  been  foreseen  in  the  memoir  of  Dr.  Lombard,  of 
Geneva,  published  in  the  same  periodical  for  January,  1834  ;  though 
even  here  the  results  are  far  less  positive  than  would  be  desirable, 
on  account  of  the  total  number  of  persons  engaged  in  each  trade  not 
having  been  mentioned.  This  talented  and  indefatigable  pathologist 
founds  his  inductions  on  a  still  larger  and  in  some  respects  a  more 
valuable  collection  of  facts.  He  divides  them  into  five  series.  First, 
1495  deaths  from  phthisis,  collected  by  himself  in  the  different  hos- 
pitals of  Paris,  and  contrasted  with  a  table  oï general  mortality  in  the 
same  professions,  published  by  M.  Villermé,  but  taken  in  another 
year.  Secondly,  676  cases  in  the  general  hospital  of  Hamburg, 
arranged  and  contrasted  as  above.  Thirdly,  572  phthisical  cases  in 
a  hospital  of  Vienna.  Fourthly,  the  memoir  of  M.  Benoiston  de 
Chateauneuf.  Fifthly,  88v!9  deaths  collected  from  the  registers  of 
Geneva,  of  which  1003  were  from  phthisis  ;  giving  an  average  of  114 
deaths  out  of  every  1000  deaths  from  diseases  in  general.  This  last 
division  is  the  most  valuable,  since  it  presents  materials  for  the 
comparison  we  have  already  referred  to.  Dr.  Lombard's  researches 
are  therefore  founded  on  a  total  of  4300  deaths  from  phthisis,  and 
54,572  individuals,  exercising  220  different  occupations. 

The  third  source  to  which  we  would  particularly  refer  is  the  inter- 
esting volume  of  Mr.  Thackrah,  on  The  effects  of  Arts,  Trades  and 
Professions,  Sfc,  on  Health  and  Longevity,  2d  edition,  London,  1832. 
This  we  believe  is  the  only  work  of  the  kind  published  in  England, 
and  the  reader  will  find  in  it  much  valuable  information,  and  discover 
many  proofs  of  the  author's  talent  and  research.  The  extent  of  in- 
quiry which  it  embraces  necessarily  precludes  those  accurate  numeri- 


INFLUENCE    OF    DUST.  473 

cal  details  which  are  indispensable  for  arriving  at  rigorous  conclu- 
sions. Phthisis  has  also,  from  the  nature  of  the  work,  been  only 
considered  as  one  of  many  other  diseases  to  which  our  manufacturing 
and  other  classes  are  liable,  and  the  author's  pathological  views  with 
regard  to  the  nature  and  causes  of  this  disease,  have  insensibly  bias- 
ed his  researches  and  modified  his  conclusions.  He  says,  page  98, 
"No  agents  excite  tubercular  development  more  than  irritation  of  the 
bronchial  membrane.  Much,  I  conceive,  depends  on  the  size  and 
Jigure  of  the  particles  Avhich  enter  the  air-tube.  The  dust  from  the 
roads  produces  no  apparent  mischief,  while  the  mason's  chippings  from 
the  stone  occasion  serious  and  often  fatal  injury  to  the  lungs."  (As 
if  no  other  and  moi-e  important  considerations  did  not  influence  this 
result.)  "  The  dust  from  old  iron,  which  is  thrown  off  so  copiously 
as  to  deposit  a  thick  brown  layer  on  the  dress  of  the  dealers  of  this 
article ,  produces  710  inconvenience,  while  the  less  apparent  detach- 
ment of  particles  from  the  file,  is  decidedly  baneful  to  the  workers  in 
iron.  It  is  then  the  forjn  rather  than  the  material,  the  spiculiE,  the 
angular,  or  pointed  figure  of  the  particles  detached,  which  we  con- 
ceive the  chief  cause  of  the  injury.  The  bronchial  membrane  is 
mechanically  irritated  or  wounded  ;  and  fi'om  the  daily  repetition  of 
this  injury,  the  lungs  at  length  become  seriously  diseased,  and  a  vast 
majority  die  consumptive!" 

With  these  impressions  upon  the  mind,  much  misconception  as  to 
the  really  active  causes  of  phthisis  will  continue  to  prevail,  and  many 
useless  preventive  measures  be  adopted.  No  really  conclusive  re- 
searches can  be  made  under  the  influence  of  such  preconceived,  and 
we  believe  erroneous  opinions.  There  are  other  materials,  of  which 
we  shall  avail  ourselves  in  the  course  of  these  remarks  ;  they  will  be 
mentioned  under  the  particular  divisions  to  which  they  are  applicable. 
We  shall  now  examine  the  evidence  adduced  on  some  of  the  most 
important  influences  resulting  from  different  occupations. 

Influence  of  Dust  in  the  production  of  Phthisis. 

No  opinion  has  been  more  prevalent,  than  that  those  who  are  ex- 
posed to  the  inhalation  of  the  dust  of  vegetable,  mineral,  or  animal 
substances,  are  peculiarly  liable  to  phthisis,  and  on  the  supposition 
that  consumption  was  essentially  a  disease  of  the  lungs,  and  in  the 
L   3 


4'4  translator's  appendix. 

great  majority  of  instances  the  result  of  bronchial  inflammation,  no 
conclusion  --.vas  more  natural  or  more  probable.     The  reader  cannot, 
Tve  think,  have  impartially  examined  the   evidence  on  the  influence 
of  bronchitis,  acute  or  chronic,  in  the  production   of  phthisis,   and 
reflected  on  the  general  deposition  of  tuberculous  matter  which  takes 
place  in  this  disease,   with   many  other  circumstances  attending  its 
progress  and  invasion,  and  retain  his  probably  previous  opinion  as  to 
the   influence    of  bronchial  inflammation   on   pulmonary  tubercles. 
Once  remove  from  the  mind  the  impression  of  a  necessary  connexion 
between  bronchitis  and  tubercles,  and  we  feel  persuaded  that  the  ex- 
amination of  the  evidence  brought  forward  on  the  subject  of  dust, 
will  terminate  in  the  conviction  that  this  agent  exerts  at  most  but  a 
very   secondary   and   unimportant   influence    in   the    production   of 
phthisis,  compared  with  other  causes  to  Avhich  we  shall  have  occasion 
to  refer.     The  question  is  far  more  than  one  of  speculative  interest, 
as  it  has  already  given  rise  to  the  exercise  of  great  talent  and  in- 
genuity, in  inventing  means  for  the  removal  of  an  evil  which  by  many 
has  been  regarded  as  the  most  fatal  to  which  the  manufacturing  classes 
are  liable.     (Would  that  it  were!)     It  is  evident  that  a  comparison 
of  the  mortality  from  consumption  in  a  list  of  dusty  occupations,  such 
as  those  of  bakers,  charcoal-men,  grain-market  porters,  thread-makers, 
cotton-spinners   and  rag-pickers  (and  we  might  have  fixed  on  any 
other  list)  is  utterly  incapable  of  deciding  the  predisposing  influence 
of  dust  in  the'production  of  the  disease.    The  other  influences  attend- 
ing these  occupations,  which  are  admitted  to  be  still  more  powerfully 
predisposing  to  phthisis,  reduce  the  common  element   of  dust  to  a 
mere  cypher  in  the  account.     Some,  working  in  the  open  air  ;  others, 
in  close-heated  rooms  ;    some   actively    employed,  while  others  are 
confined  to    a  sedentary  occupation,  &c.    &c.,   at  once   show  how 
necessarily  insecure  all  our  results  must  be  from  such  varying  and 
complicated  materials.     As  another  general  principle  it  may  be  ad- 
vanced, that  in  a   change  of  particles  a  change  of  employment  is 
included,  and  precisely  as  dust  is  evolved  from  hard  substances,  and 
IS  more  or  ]ess fine  in  its  texture,  the  occupation  of  the  workman  is 
sedentary,  his  posture  confined,  and  muscular  exercise  limited  to  the 
upper  extremities.     Now  these  last  causes  are  admitted  by  all  as 
most  strongly  predisposing  to  phthisis  (proved  by  their  estimation  in 


INFLUENCE    OF    DUST.  475 

occupations  where  dust  is  not  included),  and  we  would  ask  why  their 
influence  should  be  diminished  by  the  presence  of  another  apparent 
cause,  more  consonant,  it  is  true,  with  our  preconceived  ideas  as  to 
the  natui'e  of  the  disease,  but  which  is  not  present  in  those  occupa- 
tions where  the  average  mortality  from  phthisis  is  the  highest  ?  No  evi- 
dence is  more  universally  cited  on  this  subject  than  that  of  Dr.  Knight, 
of  Sheffield  (Vide  JYorth  of  England  Med.  and  Surg.  Journal,  August 
and  November,  1830).  It  does  indeed  incontestably  prove  that  the 
occupation  of  grinding  steel  instruments,  unusually  tends  to  shorten 
life  and  induce  phthisis.  Dust,  —  dust  is  the  explanation;  but  we 
think  the  evidence  brought  forward  in  its  support  tends  to  an  opposite 
conclusion.  -We  find,  in  fact,  that  the  grinders,  previous  to  the  com- 
mencement of  the  last  century,  were  not  an  unhealthy  set  of  men  ; 
at  this  time  they  carried  on  their  trade  in  the  country;  worked  in 
large  open  rooms  ;  -practised  other  deparimenls,  as  hafting  and  forging, 
and  were  often  months  with  only  four  or  five  hours  work  daily-  They 
now  pursue  their  profession  in  close  rooms,  work  sixteen  hours  a  day, 
and  are  wholly  confined  to  grinding.  The  usual  posture  is  with  the 
shoulders  elevated,  the  elbows  resting  on  the  knees,  and  the  body 
inclined  forwards.  It  is  an  interesting  though  painful  observation,  that 
the  most  dissipated  workmen  live  the  longest  !  (That  influence  must 
be  fatal  indeed  which  makes  vice  a  means  of  lengthening  life  !)  The 
same  observer  states,  that  out  of  250  workmen  employed  in  polishing 
steel,  ]54  had  chest  afi'ections;  while  in  an  equal  number  of  workmen 
pursuing  other  occupations  in  conjunction  with  polishing,  56  only 
were  affected.  There  was  not  an  example  of  a  polisher  of  forks 
reaching  his  thirty-sixth  year.  Magnets,  wire  masks,  currents  of  air 
and  moisture,  have  been  successively  tried  for  the  purpose,  of  arrest- 
ing the  metallic  particles,  but  the  mortality  has  not  been  diiimiishcd. 

It  is  impossible  not  to  be  convinced  that  the  influence  of  dust  has 
here  been  sadly  overrated,  and  blinded  observers  to  the  employment 
of  means  calculated  to  counteract  the  real  sources  of  the  evil  in  ques- 
tion. M.  Parent  Duchatelet,  in  an  interesting  memoir  on  the  effects 
of  tobacco  on  the  workmen  (Vide  ^n.  d^Hyg.  Pub,,  April,  1829),  found- 
ed on  an  accurate  examination  of  4518  individuals  employed  in  the 
different  manufactories  of  France,  and  who  are  exposed  to  the  inhal- 
ation of  irritating  vegetable  particles,  found  that  they  wore  not  at- 


476  translator's  appendix. 

all  pe'.n'iar^y  l'/^  hie  to  chest  affections,  and  that  their  general  health 
depended  on  the  quality  of  the  food  and  the  number  of  hours  they 
were  employed.  It  will  be  seen  also,  in  the  work  of  Mr.  Thackrah, 
that  chillren,  comparatively,  do  not  suffer  in  dusty  occupatio.  s  ;  this 
he  attributes  to  the  greater  force  of  the  pabulum  vitEe,  and  their  less 
liabiliti/  to  tubercular  development.  Facts  prove  the  latter  opinion  to  be 
incorrect;  the  difference  is  therefore  depending  on  some  other  cause. 
The  results  also  of  MM.  Benoiston  and  Lombard,  ('•^nïz.vi.andxi.),  on 
the  relative  influence  of  mineral,  vegetable  and  animal  particles  are 
exactly  the  inverse  of  each  other:*  the  former  making  animal  parti- 
cles the  most  prejudicial,  and  mineral  the  least  ;  thelatter  giving  a  very 
large  proportion  in  favor  of  the  mineral  particles  (177  per  1000  deaths) 
over  the  animal.  Let  the  reader  compare  these  heterogeneous  profes- 
sions, which  are  congregated  together  for  the  purpose  of  arriving  at 
these  results,  and  he  will  at  least  admit  that  if  true  in  the  abstract, 
they  are  far  from  being  demonstrated.  It  is  also  but  fair  to  notice 
that  M.  Benoiston,  while  he  finds  the  proportion  of  deaths  from 
phthisis  rather  more  considerable  in  occupations  involving  an  air 
charged  with  animal  particles,  yet  the  average  mortality  of  all  the 
different  professions  where  the  influence  of  dust  is  present,  is  not 
greater  than  the  general  average  for  occupations  not  exposed  to  this 
additional  inconvenience.  From  the  researches  of  Drs.  Young, 
Leblanc  and  Alison,  it  would  appear  that  stone-masons  are  peculiarly 
liable  to  phthisis.  It  must  however,  be  recollected,  that  compara- 
tively few  post-mortem  examinations  have  been  made  for  the  purpose 
of  determining  this  question,  and  that  the  appearances  mentioned  by 
Dr.  Alison  in  his  valuable  paper,  are  rather  those  of  inflammation  than 
tubercle.  Were  the  existence  of  tubercular  disease  ascertained,  the 
influence  of  dust  in  its  production  is  still  undecided.  The  hard 
nature  of  the  material,  the  partial  exercise  of  the  body,  exposure  to 
varieties  of  temperature,  habits  of  intemperance,  &-c.,  probably 
exert  a  more  powerful  influence.  We  find,  in  fact,  (Vide  Benoiston, 
page  27),  that  oui  of  887  quarry-men,  551  stone-cutters,  and  GO 
marble-workers,  the  proportion  of  phthisis  was  less  than  the  general 
average.     In  a  department  of  France  (Meusnes)  celebrated  for  the 

*  From  data  obtaineil  in  the  cities  of  Paria  and  Geneva.  —  H.  I.  B. 


INFLUENCE    OF    MOISTURE.  477 

fabrication  of  mill-stnnes,  in  a  period  of  seventeen  years  no  increase 
of  mortality  from  phthisis,  conipared  with  other  departments  where 
this  occupation  was  not  genera],  could  be  detected.  M.  Thackrah 
also  found  no  liability  to  phthisis  (which  could  be  attributed  to  their 
employment)  in  plasterers,  turners,  lime-workers  and  whitewashers. 
Let  us  terminate  these  remarks  by  citing  the  conclusion  to  which 
Dr.  Lombard  arrives  by  a  review  of  the  lohole  of  his  facts  (CG),  viz., 
that  the  influences  which  modify  the  system  in  general,  such  as  a 
sedentary  life,  &c.  &c.,  are  more  active  in  the  production  of  phthisis 
than  those  acting  lor.ally  upon  the  lungs,  as  dust,  vapors,  &c.  ;  and  if 
we  reflect  that  the  latter  agents  are  never  present  independently  of 
the  former,  their  real  activity  as  causes  of  pulmonary  tubercles  is  at 
best  but  problematical.  Our  conclusions  are  in  some  degree  opposed 
to  the  opinion  of  Dr.  Clarke,  in  his  admirable  essay  already  referred 
to,  but  that  distinguished  observer  admits  that  "  in  almost  every  in- 
stance the  sufferers  are  exposed  to  causes  (independently  of  dust) 
fully  adequate  to  the  production  of  the  tuberculous  cachexia.'* 

We  refer  the  reader  to  the  original  memoirs  for  full  information  j 
our  object  in  these  remarks  is  to  remove  that  settled  conviction  so 
generally  prevalent,  as  to  the  influence  of  a  local  cause  on  the  pro- 
duction of  phthisis.  We  again  say,  that  the  nature  of  the  disease  is 
a  powerful  à  priori  argument  against  the  influence  of  dust  of  any 
description,  and  that  the  direction  hitherto  given  to  our  opinions  and 
preventive  measures  has  tended  to  distract  our  attention  from  the 
observation  of  more  important  and  active  causes.  We  are  now,  let 
it  be  remembered,  solely  considering  the  inhalation  of  dust  in  refer- 
ence to  phthisis.  Its  presence  can  never  be  beneficial,  and  its  action 
on  the  bronchial  and  digestive  mucous  membrane  is  no  doubt  often, 
and  probably  always  more  or  less  injurious.  It  is  not,  therefore,  our 
wish  to  discourage  the  use  of  any  means  by  which  the  inconvenience 
may  be  diminished,  but  to  prove  that  its  immediate  action  upon  the 
pulmonary  organs  has  hitherto  been  greatly  exaggerated. 

Influence  of  Moisture. 

The  evidence  on  this  subject  is  perhaps  more  uniform  and  satisfac- 
tory than  on  any  other,  and  tends  strongly  to  expose  the  fallacy  of 


478  tkanslator's  appendix. 

theoretical  opinion.  Tanners,  dyers,  wool-scourers,  brewers,  washer- 
women, and  many  other  occupations  in  which  the  upper  or  lower  ex- 
tremities are  exposed  to  wet,  and  the  air  charged  with  aqueous 
vapors,  present  fewer  cases  of  consumption  than  almost  any  others. 
The  testimony  of  Mr.  Thackrah  and  Dr.  Lombard  on  this  subject  is 
unanimous,  and  M.  Benoiston  is  only  in  contradiction  with  regard  to 
the  washerwomen  of  Paris,  who,  as  Dr.  Lombard  observes,  pursue 
their  occupation  under  peculiar  circumstances,  and  on  that  account 
offer  no  criterion  for  the  same  employment  in  other  countries.  Brick- 
makers  (Thackrah)  who  work  half  naked  and  with  their  bare  feet  in 
puddle  all  day,  are  not  more  liable  to  thoracic  affections  than  men 
whose  occupations  is  under  cover,  and  dry.  Longevity  is  common. 
M.  Parent  Duchatelet,  states  (^nn.  (THyg.  July,  1830),  that  "  débar- 
deurs" of  Paris,  or  those  who  are  employed  in  removing  the  wood  for 
fuel  from  the  river,  where  it  is  floated  down  in  rafts,  and  who  spend 
the  greater  part  of  the  day  nearly  all  the  year  round,  with  their  legs  im- 
mersed in  the  water,  are  less  liable  to  chest  affections  than  the  majority 
of  workmen,  and  their  general  health  is  remarkably  good.  These  re- 
searches are  founded  on  the  personal  examination  of  670  men,  who 
are  constantly  pursuing  this  occupation.  This  strikingly  coincides 
with  the  very  general  opinion  that  consumption  is  rare  in  marshy 
districts.  A  general  practitioner  at  Swineshead  in  Lincolnshire,  has 
seen  only  two  cases  in  sixteen  years.  Dr.  Harrison  of  Horncastle, 
in  the  same  county  (Vide  Med.  and  Phys.  Journ.,  t.  viii.  page  225. 
1802),  confidently  asserts  that  consumption  is  less  frequent  in  the 
marshy  districts,  than  in  other  parts  of  his  neighborhood.  Cases 
occurring  in  a  dry  situation  were  checked  by  a  removal  to  one  sur- 
rounded by  fens.  The  ingenious  and  accurate  Dr.  Wells  (Vide 
ŒVans.  Soc.  Med.  Chir.  vol.  iii.  page  471.  Lend.  1812,)  brings  for- 
ward a  variety  of  observations  on  this  subject.  He  attempts  to  prove 
that  the  causes  of  intermittents  induce  a  state  of  constitution  which 
is  a  protection  from  consumption,  and  says  that  in  countries  where 
one  prevails  the  other  is  always  absent,  or  at  least  much  less  preva- 
lent. He  recommends  children,  predisposed  to  consumption,  to  be 
sent  to  schools  in  fenny  districts,  or  to  universities  in  Holland.  Mor- 
ton, Raulin,  Rush,  Southey,  and  others,  decidedly  recommend  a  dry 
climate,  but  their  advice  seems   principally  founded  on  theoretical 


A    DRY    AND    HOT    ATMOSPHERE.  479 

views.  Compared  with  the  statistical  results  to  Avhich  we  have 
alluded,  the  evidence  of  Dr.  Wells  and  others  is  not  without  consid- 
erable interest,  and  numerical  details  from  the  marshy  districts  of 
England  would  be  highly  desirable.  The  effect  of  moisture  on  con- 
sumption may  also  be  indirectly  inferred,  by  considering  the  influ- 
ence of  opposite  conditions,  viz., 

A  Dry  and  Hot  Atmosphere. 

Dr.  Lombard,  (Jinn.  Jan.  1834),  in  244  deaths  among  persons  ex- 
posed to  this  influence,  as  enamellers,  file  makers,  smelters  and 
founders,*  finds  the  average  of  phthisis  more  than  double  that  of  the 
preceding  class.  The  first  was  53  per  1000,  the  last  127.  He  also 
thinks  that  in  certain  occupations,  as  in  those  of  watchmakers,  jew- 
ellers, and  goldsmiths,  the  mortality  from  phthisis  may  in  part  be 
attributed  to  the  hot  and  dry  atmosphere  to  Avhich  they  are  exposed. 
Mr.  Thackrah,  on  the  other  hand,  from  the  observation  of  sugar  re- 
finers, men  employed  in  the  dryhouses  of  cloth,  in  singeing  cloth, 
stuff  pressers,  calenderers,  glass  workers,  stovers,  iron  founders, 
many  of  whom  are  constantly  exposed  to  sudden  changes  of  temper- 
ature, did  not  find  any  peculiar  predisposition  to  pectoral  affections, 
nor  any  prevalence  of  those  complaints  so  commonly  attributed  to 
this  cause.  It  will  be  recollected  that  workmen  in  these  depart- 
ments are  generally  subject  to  great  muscular  exercise  and  almost 
constant  activity  of  the  cutaneous  functions. 

Animal  Emanations. 

There  is  but  one  opinion  on  this  subject,  viz.,  that  individuals  ex- 
posed to  their  influence  are  less  liable  than  others  to  consumption. 
Butchers,  tanners,  leather  dressers,  candle  makers,  nurses,  soap 
boilers,  knackers,  or  those  engaged  in  killing  and  cutting  up  dead 
horses  (Vide  Lond.  Med.  and  Phys.  Journ.,  vol.  vi.),  men  employed 
in  the  dissecting  rooms,  in  exhumations,  catgut  makers  (Labarraque), 

*  Out  of  forty-seven  deaths  not  one  was  from  phthisis,  which  Dr.  Lombard 
thinks  may  be  attributed  to  the  moisture  which  their  occupation  requires. 


480  translator's  appendix. 

nightmen,  are  mentioned  without  any  exception,  as  enjoying  a  high 
standard  of  health  and  freedom  from  pulmonary  complaints. 

Vegetable  Emanations. 

Those  who  work  in  the  open  air  as  agriculturists,  gardeners,  florists, 
and  who  are  liable  to  emanations  from  living  plants,  are  decidedly 
among  the  most  healthy.  The  occupation  of  crushing  rape  and  mus- 
tard seed  appears  peculiarly  beneficial,  (I'hackrah,  page  58).  Starch 
makers,  bakers,  &c.,  who  are  exposed  to  the  effects  of  vegetable 
fermentation  do  not  appear  affected,  and  from  the  interesting  re- 
searches of  M.  Parent  du  Chatelet  and  M.  Girodet  in  Ann.  (THyg. 
Pui.,  March,  1832,  on  the  maceration  of  flax,  it  is  probable  that  many 
of  our  generally  received  opinions  respecting  the  influence  of  vege- 
table decomposition  on  health  are  erroneous. 

Mineral  Emanations. 

The  evidence  relative  to  mercurial  vapors  is  very  contradictory, 
and  insufficient  to  determine  their  real  influence  in  the  production  of 
phthisis.  At  Geneva,  phthisis  among  gilders  is  rare  ;  at  Paris  it  ap- 
pears frequent.  The  effects  of  lead,  antimony,  &c.,  while  they  act 
powerfully  on  the  nervous  and  digestive  systems  do  not  appear  to 
predispose  to  phthisis.  The  tendency  of  metallic  fumes  to  produce 
scorbutic  symptoms  and  that  of  mercury  to  maintain  an  alkalescent 
state  of  the  fluids,  would  both  militate  theoretically  against  their  favor- 
ing tubercular  deposition. 

Influence  of  Impure  Air. 

Dr.  Lombard,  by  a  comparison  of  all  the  professions  carried  on  in 
the  open  air  or  in  workshops,  found  the  proportion  of  deaths  from 
phthisis  double  among  the  latter,  and  this  proportion  increased  as 
the  apartments  were  close,  narrow,  and  imperfectly  ventilated.  Other 
facts,  however,  prove  that  an  impure  atmosphere,  when  not  associated 
with  other  deleterious  influences,  cannot  be  regarded  as  peculiarly 
predisposing  to  phthisis.  In  No.  107  of  the  Edin.  Med.  and  Surg. 
Journal  there  is  an  interesting  paper  by  Mr.  Watson,  surgeon  of 
Wanlockhead,  a  mining  district.      After  an  experience  of  fifteen 


INFLUENCE    OF    AN    ACTIVE    LIFE     IN    THE    OPEN    AIR.    481 

years,  he  concludes  that  miners  are  not  more  liable  to  phthisis 
than  others.  He  gives  an  account  of  74  men,  working  during  four  or 
five  months,  for  sixteen  hours  daily,  in  a  mine  where  a  candle  burned 
with  difficulty.  Not  one  was  attacked  with  any  pulmonary  affection. 
The  average  mortality  among  the  miners  was  less  than  among  the 
other  inhabitants.  In  Annales  d'Hyg.  Pub.,  Oct.  .1829,  M.  Parent 
Duchatelet  gives  a  tabular  view  of  the  health  of  32  workmen  em- 
ployed in  cleansing  tlie  sewers  of  Paris.  Their  ages  varied  between 
seventeen  and  fifty-five,  and  they  had  pursued  the  occupation  from 
six  months  to  fifteen  years.  Not  one  became  phthisical,  or  presented 
any  chest  affection.  Colliers  do  not  appear  liable  to  phthisis,  and 
though  many  species  of  mining  interfere  with  the  general  health,  con- 
sumption does  not  seem  to  prevail.  Dr.  Forbes,  in  his  notes  to 
Laennec,  says,  that  the  great  majority  of  miners  in  Cornwall  are  de- 
stroyed by  chronic  bronchitis.  If  consumption  is  rare  under  these 
circumstances,  it  would  be  a  striking  confirmation  of  M.  Louis's 
opinions  on  the  distinct  nature  of  bronchitis  and  tubercles. 

Influence  of  an  Active  Life  in  the  Open  Air. 

On  this  point  it  may  be  sufficient  to  state  that  all  occupations  in- 
volving these  two  conditions  are  admitted  by  every  observer,  to 
present  a  much  smaller  proportion  of  individuals  attacked  by  phthisis 
than  any  others  :  husbandmen,  butchers,  carters,  coachmen,  sailors, 
coopers,  quarrymen,  &c.,  may  be  cited. 

Influence  of  a  Sedentary  Life,  with  a  confined  posture  of  the 

'Body. 

Of  all  the  causes  which  seem  directly  active  in  the  production  of 
phthisis,  this  appears  the  most  general  and  influential  ;  it  must  never 
be  lost  sight  of  when  estimating  the  predisposing  tendency  of  par- 
ticular professions.  However  variable  the  situation  of  the  individual 
in  every  other  respect,  wherever  these  two  conditions  are  present, 
phthisis  may  be  said  to  prevail,  and  its  prevalence,  according  to  Dr. 
Lombard,  (Ann.  (THyg.,  Jan.  1834,  page  33,)  is  in  proportion  to  the 
M    3 


482  translator's  appendix, 

more  or  less  muscular  exercise  certain  sedentary  occupations  require. 
As  a  general  rule  also,  sedentary  employments  are  more  fatal  among 
women  than  men.  Tailors,  shoe-binders,  shoemakers,  milliners, 
lace-makers,  printers,  engravers,  jewellers,  watchmakers,  clerks,  &c. 
&c.,  may  be  more  particularly  regarded  as  the  victims  of  phthisis  ; 
and  in  our  manufactories,  there  is  no  doubt  that  a  far  greater  number 
of  consumptive  patients  is  produced  by  the  want  of  exercise  and  a 
contined  posture  of  the  body,  than  by  those  special  and  in  general 
local  influences  to  which  the  disease  has  been  so  often  erroneously 
attributed.  It  will  be  at  once  seen  to  what  an  extensive  portion  of  our 
population,  both  in  the  middle  and  lower  classes,  these  remarks  are 
applicable,  and  consequently  the  immense  importance  of  being  aware 
of  the  fatal  tendency  of  an  influence,  which  has  been  often  over- 
looked or  regarded  as  secondary  to  other  causes  which  perhaps  may 
now  be  considered  as  comparatively  inert.  The  increased  mortality 
among  females  arises  not  only  from  their  being  principally  exposed 
to  the  influences  we  are  considering,  but  from  their  great  privations 
on  account  of  their  diminished  wages,  &c.,  and  other  bodily  derange- 
ments peculiarto  the  sex.  The  number  of  hours  the  workmen  are 
employed,  the  time  allotted  for  their  meals,  and  the  quality  of  their 
food,  no  doubt  powerfully  modify  the  results,  but  we  have  no  positive 
information  by  which  we  may  define  the  extent  of  these  influences. 
There  is  one  conclusion  in  Dr.  Lombard's  memoir,  which  may  per- 
haps be  illustrative  of  the  influence  of  food,  viz.,  that  the  poorer  classes 
are  twice  as  liable  to  phthisis  as  those  in  easy  circumstances.  It  is 
founded  upon  comparing  the  number  of  professions  which  are  above 
or  below  the  general  average  in  either  division,  and  since  sedentary 
habits  and  a  confined  posture  of  the  body  are  more  or  less  common 
to  all,  this  great  difference  in  the  frequency  of  phthisis,  may  in  part 
at  least  be  attributed  to  food. 

There  does  not  appear  to  be  any  foundation  for  the  opinion  that 
occupations  requiring  OToZeni  e.rerase  of  the  upper  exlremities,  (as  those 
of  backsmiths,    sawyers,  locksmitlis,  &-c.),  predispose  to  phthisis. 

Exercise  of  the  Vocal  Organs. 

M.  Benoiston  was  only  able  to  collect  24  examples  of  occupations  in- 
volving this  condition,  and  among  these  there  was  no  peculiar  tendency 


NFLUENC  ES    WHICH    PREDISPOSE    TO    PHTHISIS.        483 

to  phthisis  (Ann.  d^Hyg.^Jiûy,  J831.)  Dr.  Lombard  fully  confirms  this 
result.  Out  of  254  deaths,  including  schoolmasters,  preachers,  profes- 
sors, barristers,  musicians  and  officers,  the  mortality  from  phthisis  was 
only  75  per  1000  deaths,  while  we  have  already  stated  that  the  gen- 
eral average  from  all  professions  indiscriminately  was  114.  The 
exercise  therefore  of  the  vocal  organs  is  beneficial  rather  than  in- 
jurious. The  reader  must  not  forget  that  we  are  considering  the 
activity  of  different  influences  in  the  development  of  tubercles,  not 
their  effects  on  individuals  who  are  already  tuberculous  ;  and  although, 
for  the  sake  of  brevity,  we  have  often  resorted  to  the  simple  form  of 
assertion,  the  preceding  remarks  are  based  upon  a  very  large  series 
of  observations,  collected  by  different  observers,  and  are  not  to  be 
confounded  with  the  innumerable  vague  and  indefinite  surmises 
which  we  find  scattered  through  the  various  monographs  onphthisis_ 
The  necessity  for  examining  a  large  mass  of  facts,  and  reuniting  a 
variety  of  professions  in  which  the  influence  of  some  common  con- 
dition may  be  traced,  must  be  apparent  to  all.  An  infinitude  of  ac- 
cessory causes  may  interfere  with  accurate  conclusions,  when 
bounding  our  examination  to  particular  occupations  ;  but  the  errors 
to  which  our  details  are  always  more  or  less  liable,  are  corrected  by 
a  greater  extent  and  variety  of  materials.  It  is  to  the  partial  obser- 
vation of  particular  facts  that  we  may  attribute  the  contradictory 
nature  of  the  evidence  on  the  causes  of  consumption. 

In  concluding  our  remarks  upon  the  influence  of  professions  on 
phthisis,  we  will  briefly  enumerate  those  general  causes  which  may 
be  regarded  as  injurious  or  preservative. 

Influences  which  predispose  to  Phthisis. 

1st.  A  sedentary  life,  more  especially  when  associated  with  a  con- 
fined posture  of  the  body.  2d.  Bad  quality  or  insufficent  quantity  of 
food.  3d.  The  impure  air  of  workshops,  4th.  A  dry  and  hot  atmos- 
phere, with  a  variety  of  mineral  and  vegetable  emanations  ;  the  effects 
of  which,  however,  independently  of  those  influences  already  stated, 
are  far  from  being  proved.  5th,  The  action  of  different  kinds  of  dust, 
the  activity  of  which,  like  the  preceding,  is  in  all  probability  very 
much  less  than  has  been  hitherto  supposed. 


484         translator's  appendix. 


Preservative  Influences. 

1st.  Muscular  exercise  in  the  open  air.  2d.  An  air  charged  with 
animal  emanations.  3d.  Moisture.  4th.  Exercise  of  the  vocal  organs. 
5th.  Nutritive  food. 

The  essential  practical  deduction  from  the  foregoing  details  is,  that 
continued  sedentary  employment,  a  confined  posture  of  the  body,  and  the 
want  of  air,  exercise,  and  wholesome  food,  are  the  immensely  pre- 
ponderating causes  of  phthisis  ;  and  that  other  influences  acting 
locally  on  the  lungs,  and  which  have  always  been  regarded  as  most 
deleterious,  are  supported  with  comparative  impunity,  when  disasso- 
ciated from  those  we  have  first  enumerated. 

There  are  few  evils  which  cannot  at  least  be  mitigated,  if  not 
avoided,  where  we  have  accurate  ideas  of  the  causes  which  produce 
them  ;  and  the  means  to  be  adopted  for  diminishing  the  victims  to 
consumption,  are  at  once  indicated  by  the  inspection  of  the  fore- 
going details.  It  is  evident  that  the  attention  of  observers  has  been 
too  much  directed  to  what  may  be  considered  rather  as  accidental, 
and,  in  many  cases,  unimportant  accompaniments,  than  to  the  really 
active  and  efficient  causes  of  phthisis.  The  registers  of  mortality 
prove  that  our  prophylactic  measures  have  hitherto  failed  ;  the  sub- 
ject therefore  demands  renewed  investigation,  and  its  vast  impor- 
tance entitles  it  to  our  most  serious  attention.  The  infinite  sub- 
division of  labor  which  the  increasing  and  artificial  wants  of  society 
involves,  is  daily  multiplying  the  sources  of  phthisis,  and  without 
adopting  some  effectual  preventive  measures,  this  fatal  scourge  upon 
the  manufacturing  and  commercial  prosperity  of  England,  will  annu- 
ally extend  its  baneful  influence.  Tn  what  those  preventive  meas- 
ures must  consist  to  be  really  effectual,  we  shall  briefly  point  out  in 
our  remarks  on  treatment. 

Influence  of  Climate. 

On  no  subject  has  more  been  written  or  less  satisfactory  informa- 
tion been  obtained  ;  the  ideas  of  a  changeable  climate  and  phthisis 
seem   almost   inseparable,   and  more   particularly   with  respect  to 


INFLUENCE    OF    CLIMATE. 


485 


England,  consumption  has  been  regarded  as  one  of  those  necessary 
indiû-enous  evils,  to  which,  as  a  nation,  we  are  inevitably  doomed. 
If  however,  we  reflect  that  no  climate  is  exempt  from  phthisis,  that 
in  the  northern  and  torrid  zones  it  is  far  less  general  than  in  the  more 
temperate  regions  of  the  globe  ;  tliat  in  the  same  climate  its  relative 
prevalence  among  particular  classes  of  individuals  is  immensely  dif- 
ferent ;  that  in  countries  where  this  disease  is  unusually  frequent,  those 
who  are  least  exposed  to  its   influence,  are  precisely  those  most  ex- 
posed to  the  vicissitudes  of  the  climate  ;  we   cannot  but  confess  that 
the  importance  of  the  latter  in  the  production  of  phthisis  has  been 
much  exaggerated  and  far  too  exclusively  considered.     Its  action  on 
the  human  frame  must  be  admitted  to  be   extremely  complex  ;  the 
ultimate  result,  as  Dr.  Copland  says,  arising  chiefly  from  the  com- 
bined operation  of  heat,  light,  electricity,  atmospheric  pressure,  the 
various  emanations  arising  from  the  soil,  and  the  productions,  vege- 
table and  animal,  constituting  the  food  of  man.     Independently  of 
these  numerous  considerations,  the  grand  and,  in  our  opinion,  most 
important  influence  of  civilization  renders  the  appreciation  of  climate 
peculiarly  difficult;  and  the  simple  inspection  of  mankind  in  different 
countries,  forces  us  to  admit,  that  the    most  vaiiabh  climates,  not- 
withstanding   the    disadvantages   imputed   to  them,    are    the   most 
favorable  to   the  advancement  of  the    various   bodily   and   mental 
powers.      Countries  thus   circumstanced  are  rather  benefited  than 
injured   by    this    state    of  the  weather    and    seasons,    as    is  illus- 
trated in  the  robust  frames,  mental   activity,   and  the   longevity  of 
their  inhabitants.     The  physical  and  moral  condition  of  the  British 
Isles,  Denmark,  Sweden,  and  the  more  continental  districts  of  West- 
ern Europe,  demonstrate  this  fact.     In  no  country  are   the  animals 
finer  than  in  England,  or  the  inhabitants,  viewed  as  a  community, 
more  robust,  and   if  under  these   circumstances,  a  disease  of  the 
nature  and  character  of  phthisis  is  found  to  prevail,  and  its  frequency 
can  be  traced  to  particular  classes  of  individuals,  evidently  exposed 
to  influences  which  are   in  no  wise  depending  on  the  climate  of  the 
countrj''  they  inhabit,  its  prevalence  must  necessarily  be  ascribed  to 
other  causes,  aud  not  attributed  to  what  has  been  too  easily  admitted 
as  a  powerful  agent  in  tubercular  disease.     The  reader  must  not 
paiatake  the  spirit  of  our  remarks,  or  suppose  that  we  are  denying  the 


486  translator's  appendix. 

influence  of  a  changeable  climate  on  delicate  predisposed  constitu- 
tions ;  nor  are  we  ignorant  of  the  fact  that  the  sudden  change  from  a 
hot  to  a'cold  climate  is  frequently  followed  by  pulmonary  consump- 
tion, but  we  are  simply  examining  the  natural  tendency  of  a  particular 
climate,  abstractedly  considered,  to  induce  tubercular  disease  in 
those  habitually  submitted  to  its  influence  ;  and  after  perusing  the 
works  of  Clarke,  Young,  Laennec,  Mosely,  Beddoes,  Wells,  Southey, 
and  Fothergill,  we  have  not  been  able  to  collect  any  conclusive 
evidence  upon  the  subject.  All  calculations  where  the  occupations, 
food,  habits,  &c.,  of  the  inhabitants  are  not  duly  considered,  may  be 
regarded  as  negative  ;  for,  having  once  demonstrated  that  the  maxi- 
nnum  of  liability  to  phthisis  in  a  country  like  England,  is  found  among 
those  least  in  contact  with  the  variations  of  its  climate,  the  influence 
of  the  latter  must  be  regarded  as  secondary  to  the  action  of  causes, 
without  the  previous  agency  of  which  it  would  have  been  compara- 
tively if  not  wholly  inert.  We  are  unable  to  favor  the  reader  with 
any  positive  evidence  on  the  relative  frequency  of  phthisis  on  the  sea 
coast  or  inland;  numerous  details  and  exact  appreciation  of  the 
changes  in  food,  occupation,  &c.,  which  one  or  the  other  involves, 
would  be  necessary  for  the  solution  of  this  important  question.  The 
most  contradictory  opinions  have  been  entertained,  and  in  the  pres- 
ent state  of  our  knowledge  we  prefer  avowing  our  ignorance,  to  the 
expression  of  an  opinion  which  can  have  little  else  for  its  support 
than  theoretical  assumption.  The  observation  by  Dr.  Rush,  that 
phthisis  is  unknown  among  the  Indians  of  North  America  and  very 
uncommon  among  the  colonists  in  the  first  stage  of  civilization,  is  most 
interesting,  and  highly  confirmatory  of  the  preceding  remarks  ;  we 
are  much  inclined  to  believe  that  were  the  influence  of  climate  un- 
connected with  all  other  causes,  the  activity  of  which  is  incontestable, 
in  the  present  state  of  our  evidence  it  would  not  admit  of  demonstra- 
tion, and  that  in  England  the  prevalence  of  phthisis  is  owing  to  the 
requirements  of  fashion  and  commerce,  rather  than  the  consequence 
of  our  much  calumniated  climate. 

Contagion  of  PhtJiisis. 

This   question  is  decided  in   the    afiirmative   by  the  majority  of 
authors,  [from  Aristotle  down  to  modern  times  ;  we  have  not,  how- 


CONTAGION    OF    PHTHISIS.  487 

ever,  been  able  to  collect  the  slightest  satisfactory  evidence  in  favor 
of  the  conclusion,  but  have  waded  through  a  mass  of  incomplete  and 
often  absurd  facts,  which  are  rather  painful  illustrations  of  the  credu- 
lity of  many  of  the  most  distinguished  ornaments  of  their  profession, 
than  data  to  regulate  the  decision  of  any  philosophical  inquirer.  The 
difficulty  of  determining  the  contagious  nature  of  a  disease  so  preva- 
lent as  phthisis,  is  very  great,  and  the  number  of  facts  necessary  for 
its  substantiation  would  be  considerable.  Without  attempting  to 
offer  any  decision  upon  the  subject,  we  may  remark,  that  the  pathol- 
ogy of  the  disease,  its  progress  and  causes,  Avhen  compared  with  what 
we  know  relative  to  diseases  whose  contagion  is  not  doubtful,  all  tend 
to  favor  the  idea  that  consumption  is  not  contagious. 

In  the  memoir  of  Dr.  Lombard  (page  fi6),  attendants  on  the  sick,  in 
hospitals  and  elsewhere,  are  invariably  classed  in  the  lists  of  Geneva, 
Vienna,  and  Hamburgh,  as  amongst  those  who  are  least  exposed  to 
phthisis.  This  fact  is  not  easily  reconciled  with  the  idea  of  con- 
tagion. The  negative  evidence  also  of  Beddoes,  Young,  Russel  and 
Portal,  is  more  decisive  than  any  which  has  been  adduced  on  the 
opposite  side.  Wherever  doubt  exists,  the  judicious  practitioner  will 
of  course  studiously  avoid  all  unnecessary  exposure;  but  there  are 
quite  sufficient  reasons,  independently  of  any  idea  of  contagion,  to 
render  the  prevention  of  the  attendance  of  delicate,  predisposed 
individuals  on  consumptive  or  other  patients,  both  prudent  and  de- 
sirable. 

Dr.  W.  Philip,  in  his  valuable  little  work  on  the  employment  of 
minute  doses  of  mercury,  page  57,  insists  strongly  on  the  influence 
of  neglected  bilious  complaints  in  the  production  of  phthisis  ;  stating, 
that  according  to  his  experience  more  than  half  of  the  cases  of  pul- 
monary consumption  are  of  this  nature,  and  might  with  certainty  be 
prevented  by  removing  the  cause  of  irritation,  before  the  nerves,  which 
convey  the  effects  of  the  irritation  to  the  lungs,  had  essentially  in- 
fluenced the  state  of  their  vessels.  The  general  pathology  of  the 
disease  renders  it  highly  probable  that  derangement  in  the  digestive 
functions  is  a  primary  and  frequent  cause  of  phthisis,  as  indeed  is 
every  influence  which  interferes  with  any  of  the  important  functions 
of  the  body,  though  from  the  almost  invariably  morbid  state  of  the 
alimentary  canal  in  conjunction  with  pulmonary  tubercles,  the  occa- 


488  translator's  appendix. 

siona]  predominance  of  gastric  over  thoracic  symptoms,  and  more 
particularly  the  special  character  of  the  alterations  observed  in  the 
liver  and  digestive  tube,  and  their  dépendance  on  the  state  of  the 
pulmonary  organs,  it  is  to  be  presumed,  that  the  direct  influence  of 
bilious  complaints  on  consumption  has  been  overrated,  and  that  the 
secondary  effects  of  tubercles  in  the  lungs  have  been  often  regarded 
as  the  causes  of  those  pulmonary  symptoms,  which  are  frequently  so 
latent  in  their  character  and  tardy  in  their  manifestation. 

It  has  been  generally  supposed  that  the  seasons  exerted  a  powerful 
influence  on  the  mortality  from  this  disease,  and  the  Hippocratic 
opinion  of  the  fatal  influence  of  autumn  has  generally  prevailed. 
The  only  numerical  details  we  have  been  able  to  collect  are  in  the 
memoir  of  M.  Benoiston  (^n7i.  (THijg.  July,  1831,  p.  19).  Out  of  12,668 
deaths  from  phthisis,  occurring  at  Milan,  Paris,  and  in  the  surround- 
ing country,  the  proportion  in  the  different  seasons  was  as  follows  : — 

Autumn, 3001 

Winter, 3109 1 

^^_>  12,668 
Spring, 3482, 

Summer, 3076 

These  results  are  almost  negative  ;  the  question  is  still  undecided, 
and  it  is  more  than  probable  that  the  result  in  each  country  will  vary 
with  the  local  peculiarities  of  the  climate. 

We  do  not  intend  occupying  the  reader's  attention  by  the  enumera- 
tion of  the  long  lists  of  supposed  causes  of  phthisis,  believing  that  it 
is  far  better  to  be  ignorant  of  the  cause  of  a  disease,  and  to  avow  this 
ignorance,  than  to  refer  it  slightly  and  without  proof  to  the  action  of 
influences  which  in  no  wise  contribute  to  its  production.  In  the 
latter  instance  we  are  wandering  in  the  dark,  exciting  unnecessary 
fears,  and  giving  useless  if  not  dangerous  advice  ;  while  by  with- 
holding our  decision,  we  remain  as  it  were  on  the  defensive,  and 
retain  that  state  of  mind  which  is  favorable  to  the  research  and  dis- 
covery of  truth.  Opinions  have  too  often  acquired  solidity  by  repe- 
tition, rather  than  by  the  addition  of  any  positive  evidence  adduced  in 
their  support;  and  it  is  so  much  easier  to  cite  the  authority  of  names 
than  that  of  facts,  and  to  coincide  in  the  opinions  of  others  rather 
than  tett  their  validity,  that  it  is  not  difficult  to  trace  the  inroads  of 


TREATI^IENT    OF    PHTHISIS.  489 

those  errors  and  absurdities  by  which  medicine  is  so  obscured  and  re- 
tarded. No  branch  of  investigation  has  more  extensively  suffered 
from  the  tendency  to  which  we  are  alluding,  than  that  of  the  causes 
of  disease.  Prejudice,  superstition,  and  system  have  principally 
labored  in  their  creation,  and  it  is  the  difficult  task  of  the  modern 
inquirer,  to  extract  truth  from  the  crude  and  amorphous  materials 
amassed  by  these  powerful  but  deceptive  agents.  The  importance, 
however,  of  the  inquiry  is  immense,  and  if  pursued  with  no  other  in- 
tention than  the  discovery  of  truth,  will  not  only  increase  the  sum  of 
our  knowledge,  but  exert  a  beneficial  influence  on  mankind  at  large. 


H. 

Treatment    of    Phthisis. 

"  C'est  c\  l'hygiène  qu'il  faut  demander  la  cure  des  affections  invétérées, 
et  surtout,  de  celles  qui  comme  la  phthisie  pulmonaire  sont  liées  au  plan 
même  de  l'organization  et  à  la  manière  dont  les  fonctions  sont  modifiées  par 
les  agents  dont  nous  sommes  journellement  influencés." — Broussais'  Phleg. 
Chron.  vol.  ii.  page  253. 

In  the  following  observations  it  is  not  our  intention  to  lay  down  any 
precise  and  definite  rules  for  the  treatment  of  consumption,  but  to 
direct  the  reader's  attention  to  some  general  conclusions  relative  to 
the  nature  of  the  disease,  founded  on  a  review  of  its  pathology  ;  to 
enumerate  some  of  the  more  prominent  preservative  and  curative 
indications  resulting  from  a  knowledge  of  its  causes  ;  and  to  give  a 
brief  outline  of  the  principal  remedies  which  have  been  successively 
proposed,  leaving  to  the  judgment  of  the  practitioner  their  selection, 
and  to  maturer  experience  the  determination  of  those  infinite  combi- 
nations on  which  their  successful  application  depends. 

Pathology  would  indeed  be  an  arid  and  thankless  science,  did  it 
only  lay  bare  the  disorganization  of  our  frame,  and  were  it  not  asso- 
ciated with  the  hope,  nay,  certainty,  of  ultimately  rationalizing  the 

N  3 


490         translator's  appendix. 

employment  of  our  therapeutical  agents.  Its  legitimate  object  is  the 
cure  of  disease,  and  though  perhaps  never  conducting  us  to  the  dis- 
covery of  specifics,  it  must  necessarily  tend  to  define  those  conditions 
against  which  our  remedies  are  directed,  and  shield  us  from  that 
painful  and  injurious  uncertainty,  invariably  attending  our  ignorance 
of  the  seat  and  nature  of  disease.  Exactly  in  proportion  as  patho- 
logical knowledge  has  advanced,  simplicity  of  treatment  has  pre- 
vailed. The  complicated  formulas  of  a  dim,  superstitious  and  fanci- 
ful physiology,  are  rapidly  yielding  to  the  more  simple  indications  of 
positive  knowledge,  and  at  the  present  moment,  perhaps  there  is  no 
surer  criterion  of  our  deficient  information  as  to  the  real  nature  of 
any  particular  affection,  than  the  variety  and  complex  character  of 
the  means  which  are  proposed  for  its  cure.  The  most  incurable  dis- 
eases abound  most  in  specifics,  and  on  the  substratum  of  our  igno- 
rance, prescriptions  accumulate  with  empirical  rapidity.  ISo  disease 
more  strongly  illustrates  the  truth  of  these  remarks  than  phthisis. 
It  has  constantly  been  the  victim  of  pharmacopseial  experiment,  while 
in  recent  researches  we  can  alone  discover  any  accurate  ideas  as  to 
its  nature  and  seat. 

From  an  impartial  review  of  the  numerous  details  scattered 
through  the  course  of  this  volume,  we  feel  justified  in  concluding. 

That  phthisis,  though  generally  commencing  in  the  lungs,  cannot 
be  regarded  merely  as  a  local  disease  of  these  organs,  but  depends 
on  some  constitutional  tendency  resulting  from  the  impression  of 
causes  which  especially  react  upon  the  general  health,  and  the  more 
or  less  prolonged  influence  of  which  terminates  in  the  formation  of 
tubercles. 

That  while  certain  constitutions  from  hereditary  or  other  causes, 
are  peculiarly  liable  to  this  termination,  yet  that  none  are  exempt  or 
incapable  of  becoming  tuberculous,  and  from  the  nature  of  the 
causes,  the  universalily  of  the  disease,  and  the  variety  of  organs  in 
which  tubercular  deposit  takes  place,  it  cannot  be  regarded  as  a 
specific,  but  as  an  almost  physiological  and  necessary  consequence  of 
the  more  or  less  prolonged  application  of  influences,  which  interfere 
with  tlie  normal  discharge  of  the  nutritive  functions  of  the  body. 

Tiial  no  age  is  exempt  from  tubercular  formation. 

That  in  children  tubercles  in  general  occupy  a  greater  number  of 


TREATMENT    OF    PHTHISIS.  491 

organs  than  in  the  adult,  and  are  not,  as  is  the  case  after  the  age  of 
fifteen,  invariably  first  deposited  in  the  lungs. 

That  a  predisposition  to  phthisis  may  exist  an  indefinite  period  of 
time,  but  under  these  circumstances  the  action  of  almost  any  influ- 
ence interfering  with  the  general  health,  may  give  rise  to  tubercular 
development. 

That  tubercles  may  remain  latent  in  the  lungs,  and  with  the  ex- 
ception of  those  instances  in  which  they  are  rapidly  developed,  fre- 
quently do  not  in  their  crude  state,  and  even  occasionally  when 
softened  (vide  cases  of  latent  phthisis),  give  rise  to  characteristic 
constitutional  symptoms. 

That  the  number  of  organs  affected,  and  the  extent  of  tubercular 
deposition  in  the  lungs,  may  be  regarded  as  in  general  proportionate 
to  the  predisposition  previously  existing,  but  that  in  many  cases  of 
acute  phthisis,  the  lungs  may  be  extensively  tuberculated  as  well  as 
the  other  organs,  while  in  many  subacute  and  long  protracted  cases, 
the  portion  of  the  pulmonary  tissue  which  is  affected,  and  the  amount 
of  tubercular  deposition  generally,  may  he  inconsiderable. 

That  tuberculous  matter  may  be  at  once  secreted  in  the  form  to 
which  the  term  "  tubercle"  is  usually  applied,  but  that  in  the  lungs 
especially,  and  occasionally  in  the  other  organs,  some  previous  modi- 
fications of  structure  occur,  which  may  be  regarded  as  preliminary 
steps  to  the  formation  of  tubercles,  and  depending  on  the  same  dia- 
thesis. 

That  no  incontestable  evidence  exists  to  prove  the  absorption  of 
tubercles  in  the  lungs  ;  but  the  presence  of  cretaceous  deposit,  and 
the  history  of  many  individual  cases,  render  the  fact  highly  pro- 
bable. 

That  tubercular  excavations  are  capable  of  cure  independently  of 
all  medical  aid. 

That  the  softening  of  tubercles  in  the  lungs  is  usually  accompa- 
nied with  both  local  and  generally  inflammatory  symptoms,  and  that 
the  progress  and  duration  of  the  disease  are  subject  to  incalculable 
variations,  depending  on  constitutional  peculiarities  and  the  condition 
of  the  other  organs. 

That  the  lesions  of  the  digestive  tube  are  the  most  frequent  and 
important  afler  those  of  the  lungs. 


492  translator's  appendix. 

That  the  number  and  extent  of  the  secondary  lesions  are  propor- 
tionate to  the  violence  and  duration  of  the  febrile  excitement,  and 
that  several  of  these  morbid  alterations  are  equally  characteristic  of 
phthisis  with  the  more  prominent  organic  modifications  of  the  pul- 
monary organs. 

Lastly,  we  believe  in  common  with  Dr.  Clarke,  and  many  other 
pathologists,  that  the  real  cause  of  tubercles  is  a  morbid  condition  of 
the  general  system,  hereditary  in  some,  and  in  others  induced  by  a 
series  of  functional  derangements,  ultimately  affecting  the  whole 
animal  economy. 

It  would  be  easy  to  enumerate  other  pathological  peculiarities  of 
phthisis,  but  many  of  them  have  already  been  insisted  upon  in 
the  course  of  the  Avork,  and  our  object  at  the  present  moment  is  sim- 
ply to  justify  the  grand  therapeutical  deduction,  that  in  tlie  cure  of 
consumption  our  principal  reliance  must  be  placed  upon  general 
rather  than /ocaZ  measures;  to  the  latter  attention  has  hitherto  been 
far  too  exclusively  directed. 

We  have  already  remarked,  that  the  nature  of  the  really  active 
causes  of  phthisis  strikingly  confirms  the  conclusions  we  have  drawn 
from  the  examination  of  its  pathology,  and  we  shall  now  briefly  ad- 
vert to  some  of  those  practical  inferences  which  result  from  their 
consideration. 

Among  the  most  fatal  and  generally  active  causes  of  phthisis  in 
our  manufacturing  and  other  classes,  are  sedentary  occupations  and 
a  confined  posture  of  the  body.  It  needs  no  arguments  to  show  how 
they  are  to  be  counteracted.  The  workman,  whose  employment  ex- 
poses him  to  these  injurious  influences,  should  take  regular  and  daily 
exercise  in  the  open  air,  be  restricted  in  the  number  of  hours  he  is 
employed,  and  never  be  allowed  exclusively  to  follow  any  one  occu- 
pation which  experience  has  now  shown  will  almost  inevitably  shorten 
his  life  and  terminate  in  phthisis.  He  should  alternately  pursue  other 
departments  of  his  trade,  requiring  very  opposite  conditions  for  the 
muscular  system  ;  and  if  in  some  few  instances  his  manual  dexterity 
may  be  impaired,  his  life  at  least  would  be  prolonged  and  his  general 
usefulness  and  activity  increased.  However  imperative  and  multi- 
plied may  be  the  wants  of  civilized  society,  we  cannot  be  justified 
in  supplying  them  at  such  an  immense  expense  of  human  life,  and 


TREATMENT    OF    PHTHISIS.  493 

still  less  in  not  systematically  enforcing  regulations,  -which,  if  not 
obviating  the  evil,  would  undoubtedly  materially  lessen  the  amount 
of  its  influence. 

In  all  our  manufactories  where  children  are  employed,  gymnasia 
should  be  erected,  and  some  short  intermissions  from  their  con- 
fined and  sedentary  postures  be  devoted  to  active  and  Avholesome 
exercises.  Baths  should  be  provided,  by  which  not  only  cleanliness 
might  be  promoted,  but  the  important  functions  of  the  skin  invigo- 
rated ;  and  let  it  never  be  forgotten  that  charity  does  not  only  consist 
in  furnishing  an  asylum  in  which  the  wretched  victim  of  our  artificial 
wants  may  expire,  or  in  procuring  the  assistance  of  medicine  by 
which  some  temporary  relief  to  his  sufferings  may  be  afforded,  but 
in  surrounding  him  with  our  care  when  in  health,  and  in  the  exhibi- 
tion of  our  solicitude  to  prevent  those  evils,  to  which  he  is  now,  too 
often  inevitably  doomed. 

The  importance  and  extent  of  our  manufacturing  classes  are  such, 
that  all  inquiries  calculated  to  elucidate  those  causes  which  injuri- 
ously affect  their  general  health,  address  themselves  to  our  most 
serious  attention,  and  we  think  sufficient  evidence  has  been  brought 
forward  to  prove  that  those  measures  which  have  hitherto  been  put 
in  force  for  diminishing  their  liability  to  phthisis,  can  never  be  at- 
tended with  success  while  the  far  more  fatal  evils  of  a  sedentary  life 
and  confined  posture  of  the  body  are  continued.  These  remarks  are 
equally  applicable  to  a  variety  of  other  trades  and  professions,  and  it  is 
only  necessary  for  the  practitioner  to  be  aware  of  the  fact,  to  be  ena- 
bled at  once  to  seize  the  indications,  and  adapt  his  preservative  mea- 
sures to  the  peculiarities  of  individual  circumstances. 

From  what  has  preceded,  we  may  deduce  the  injurious  tendency 
of  every  thing  which  can  interfere  with  the  free  action  of  the  lungs, 
such  as  various  articles  of  dress,  the  acquirements  of  certain  accom- 
plishments, protracted  hours  of  study,  and  the  absence  of  all  free 
and  unconstrained  exercise  in  the  open  air.  To  these  may  be  added 
late  hours,  stimulating  food,  and  a  variety  of  other  details,  by  which 
gentility  is  purchased  at  the  expense  of  health,  and  a  state  of  con- 
stitution formed  which  becomes  the  prey  to  the  first  accidental  influ- 
ence to  which  it  may  be  exposed. 

The  greater  liability  of  women  to  phthisis  is  an  almost  necessary 


494  translator's  appendix. 

consequence  of  the  truth  of  the  preceding  remarks,  and  should  in- 
crease our  solicitude,  more  especially  where  any  predisposition 
exists,  early  to  enforce  our  preservative  measures. 

From  the  evidence  which  has  been  adduced  relative  to  the  effects 
of  moisture,  the  utility  of  aqueous  vapors  whenever  the  workman  is 
exposed  to  a  dry  and  heated  atmosphere,  may  be  fairly  deduced,  and 
on  similar  grounds  the  selection  of  a  moist  climate  in  preference  to 
one  of  an  opposite  description,  would  be  justified.  The  same  consid- 
eration Avould  also  point  out  the  superiority  of  a  residence  on  the  sea 
coast  ;  always  supposing  that  other  important  considerations,  such  as 
temperature,  exposure,  &,c.,  have  not  been  overlooked. 

The  influence  of  impure  air,  while  evidently  less  than  has  been 
generally  supposed,  is  still  very  sensible  under  particular  circum- 
stances, and  points  out  the  advantages  of  strict  attention  to  ventila- 
tions, the  necessity  of  lofty  and  capacious  workshops,  and  the  avoid- 
ance of  crowding  too  many  into  the  same  apartment. 

Another  and  most  important  deduction  is  the  benefit  that  would 
result  from  a  sufficiently  early  change  of  occupation  in  those  cases 
(and  they  form  the  great  majority),  where  freedom  from  labor,  and 
removal  to  a  warm  climate  are  impossible,  and  where  death  is  inevi- 
table if  the  injurious  employment  is  continued.  Those  occupations 
where  the  individuals  are  exposed  to  more  or  less  muscular  exertion, 
particularly  in  the  open  air,  to  animal  emanations  and  moisture,  as 
for  instance,  gardeners,  ploughmen,  butchers,  coachmen,  tanners, 
excisemen,  bookbinders,  dyers,  grooms,  &c.,  might  be  advantageously 
substituted,  and  would  constitute  one  of  our  principal  resources  in 
the  treatment  of  phthisis  among  the  lower  classes. 

We  again  say  that  to  be  effectual,  it  is  against  those  influences, 
the  direct  tendency  of  which  is  to  induce  that  state  of  the  constitu- 
tion which  precedes  the  development  of  tubercles,  that  our  prophy- 
lactic treatment  must  be  directed  ;  they  are  to  be  viewed  as  the 
essential  causes  of  phthisis,  the  real  sources  of  the  activity  of  those 
secondary  agents  to  whose  influence  too  exclusive  attention  has 
been  given.  "  Consumption  may  be  regarded,"  says  the  warm  and 
philanthropic  Beddoes,  "  as  a  vast  pit-fall  situated  on  the  high  road 
of  life,  which  we  have  not  sense  enough  of  our  common  interest  to 
agree  to  fill  up,  or  fence  round,"  and  it  will  still  gape  for  its  victims 


TREATMENT    OF    PHTHISIS.  495 

until  our  preservative  measures  are  guided  by  more  accurate  knowl- 
edge of  the  causes  and  nature  of  the  disease.  "There  is  certainly 
no  subject,"  says  Dr.  Clarke,  "  connected  with  health,  which  possesses 
greater  claims  to  the  attention  of  the  inhabitants  of  this  country,  than 
that  which  relates  to  the  causes  and  nature  of  that  class  of  diseases 
of  which  consumption  is  one  of  the  most  frequent  and  most  fatal 
forms.  Until  we  arrive  at  a  knowledge  of  the  state  of  the  system, 
which  leads  to  the  formation  of  tubercles,  and  of  the  circumstances 
which  induce  this  state,  we  cannot  hope  to  establish  rules  for  the 
prevention  of  consumption  upon  any  sound  principles."  We  have 
already  expressed  our  conviction  of  the  inefficiency  of  our  curative 
measures  in  the  great  majority  of  instances  q/ïer  pulmonary  tubercles 
are  formed  ;  prophylactic  treatment  is  therefore  unusually  important, 
and  we  do  not  hesitate  to  say,  in  the  prevention  of  a  disease  like 
phthisis,  would  be  unusually  successful.  In  what  it  ought  to  consist, 
the  patliology  and  causes  of  the  disease  at  once  point  out,  while  its 
selection  must  be  guided  by  the  individual  peculiarities  of  the  case. 
In  proportion  as  predisposition  exists,  more  particularly  when  asso- 
ciated with  the  peculiar  liability  of  sex,  the  greater  the  necessity  for 
an  early  and  systematic  employment  of  all  those  means  by  which  the 
general  health  may  be  supported  and  improved.  They  consist  in  arr, 
exercise,  food,  clothing,  change  of  climate  and  of  occupation,  the  use 
of  baths,  and  attention  to  the  functions  of  the  skin  and  bowels  gener- 
ally, with  the  avoidance  of  all  those  habits  and  influences  which  tend 
in  any  way  to  counteract  the  object  we  have  in  view,  viz.,  increasing 
the  tone  and  vigor  of  the  constitution.  While  in  the  vast  majority  of 
instances  our  preservative  treatment  can  only  be  partially  enforced, 
yet  there  are  few  cases  in  which  much  good  might  not  be  effected  when 
fully  aware  of  its  power,  and  we  feel  it  impossible  to  insist  too  strongly 
upon  the  immense  importance  of  adopting  means  for  the  prevenlionof 
phthisis,  believing  that  in  the  present  state  of  our  knowledge,  they  are 
alone  capable  of  materially  lessening  the  fatal  ravages  of  this  scourge 
of  civilized  man,  and  of  England  in  particular. 

We  shall  now  take  a  brief  survey  of  those  means  which  have  been 
recommended  by  the  majority  of  authors  after  pulmonary  tubercles 
are  formed;  enumerating  them  individually,  and  extending  their 
application  to  the  dififerent  periods  of  the  disease,  leaving  the  appre- 


496  translator's  appendix. 

ciation  of  their  relative  value  and  clioice  of  combination  to  the  judg- 
ment of  the  reader.  Our  object  at  the  present  moment  is  the  accu- 
mulation of  materials  for  treatment,  not  their  adaptation  to  any 
peculiar  views  we  may  ourselves  entertain. 

The  earlier  period  of  phthisis  is  usually  characterised  by  a  dry 
cough,  clear  expectoration,  pains  in  the  chest,  haemoptysis,  slight 
hectic,  increased  sensibility  to  cold,  more  or  less  emaciation,  and 
some  modification  of  the  respiratory  murmur  and  percussion  in  the 
upper  portion  of  the  chest.  It  is  in  this  stage  of  the  disease  that  we 
have  the  almost  unvarying  testimony  of  authors,  from  Hippocrates 
downwards ,  in  favor  of  a  milk  and  a  vegetable  diet  ;  and  if  we  con- 
sider the  tendency  to  and  in  general  presence  of  febrile  excitement, 
with  the  frequency  of  gastro-intestinal  derangement  in  this  affection, 
the  advantages  connected  with  such  a  diet,  as  a  general  principle, 
can  scarcely  be  contested.  There  are,  however,  many  cases  (more 
particularly  when  the  scrophulous  constitution  predominates),  where 
animal  food  and  moderate  quantities  of  malt  liquor  and  wine  might  be 
advantageously  substituted  ;  but  these  are  exceptional  cases,  and  do 
not  negative  the  united  testimony  of  the  most  judicious  and  practical 
of  our  writers,  in  favor  of  a  milk  and  vegetable  diet.  M.  Broussais 
(Vide  Phleg.  Chron.,  vol.  ii.  page  361),  adduces  some  striking  evi- 
dence in  favor  of  the  advantages  resulting  from  limiting  the  patient 
to  two  pints  of  milk,  with  from  two  to  eight  ounces  of  bread  daily, 
during  six  weeks  or  two  months.  In  the  examples  mentioned,  the 
symptoms  were  acute,  recent,  occurring  in  adults,  and  giving  every 
reason  to  suspect  (local  symptoms  are  not  mentioned)  tubercular 
deposition.  In  all,  the  result  was  most  satisfactory.  Ass's  and  goat's 
milk  may  be  tried,  should  cow's  disagree  ;  the  latter,  however,  may 
in  most  cases  be  rendered  digestible  by  boiling, —  mixing  it  with 
small  quantities  of  flour,  lime  water,  soda  water,  mineralwate  fs 
(Hoffman),  distilled  aromatic  water  (Broussais),  «Sz-c.  Should  it  still 
disagree,  we  may  try  light  broths,  animal  jellies,  gelatinous  food  in 
general  ;  various  preparations  of  rice  and  flour,  eggs,  buttermilk  ; 
oysters  have  been  also  highly  recommended,  and  may  occasion- 
ally vary  the  diet  of  phthisical  patients.  No  distinct  rules  can  be 
laid  down;  our  object  is  to  furnish  the  patient,  at  the  least  possible 
expense  of  his  organs,  studiously  avoiding  every  thing  which  stimu- 


TREATMENT    OF    PHTHISIS.  497 

lates  the  circulation  and  induces  that  state  of  the  system  which  would 
be  favorable  to  tubercular  softening.  It  is  evident  that  in  particular 
circumstances  both  these  indications  may  be  fulfilled  by  a  diet  of  a 
very  opposite  description,  and  little  more  can  be  said,  than  that  in 
proportion  as  the  symptoms  are  acute,  and  the  constitution  plethoric 
and  irritable,  must  the  diet  be  mild  and  scanty.  In  the  more  ad- 
vanced stages  of  the  disease  the  condition  of  the  digestive  organs 
must  be  our  principal  criterion  for  the  quality  and  quantity  of  in- 
gesta. 

Attention  to  clothing  is  very  important.  It  should  be  warm  in 
proportion  to  the  debility  of  the  patient,  and  the  temperature  to  which 
he  is  exposed.  Flannel,  and  Avhere  this  excites  too  great  irritation, 
leather  should  be  worn  next  the  skin.  The  feet  should  be  warmly 
and  securely  defended,  and  females  should  never  expose  their  arms 
and  chest  to  the  air,  or  vary  the  warmth  of  their  dress  at  particular 
hours  of  the  day.  Too  much  clothing  must  be  equally  avoided,  par- 
ticularly where  there  is  much  tendency  to  perspiration,  and  at  night 
it  may  in  general  be  advisable  to  substitute  calico  for  flannel  as  re- 
commended by  Dr.  Barlow. 

Exercise  in  the  open  air  should  be  regarded  as  one  of  the  most 
essential  curative  measures,  and  must  not  be  relinquished,  as  is  too 
often  the  case,  from  the  dread  of  taking  cold  ;  our  best  security 
against  this  complication  consists  in  regular  and  habitual  contact  with 
the  atmospheric  changes  around  us.  By  proper  clothing,  and  avoid- 
ing extremes  of  temperature,  incipient  cases  of  phthisis  may  be  ad- 
vantageously exposed  to  the  open  air.  All  violent  exertion,  whatever 
tends  to  accelerate  the  circulation,  and  excessive  fatigue,  should  be 
avoided.  On  few  subjects  could  such  multiplied  evidence  be  adduced, 
as  on  the  benefit  resulting  from  horse  exercise  in  phthisis.  The  prac- 
tical Sydenham  placed  his  chief  reliance  upon  it,  and  recommends 
journeys  of  some  months  undertaken  in  this  way.  The  patient,  he 
says,  should  almost  live  on  horseback,  and  attention  to  this  injunc- 
tion, he  thinks  of  greater  importance  than  rules  of  diet.  Dr.  Rush  is 
equally  convinced  of  the  efficacy  of  horse  exercise,  and  mentions  his 
having  cured  several  who  were  laboring  under  the  symptoms  of  con- 
firmed phthisis,  by  advising  them  to  become  postmen.  Russel,  Mar- 
o  3 


498  translator's  appendix. 

ryat,  Morgagni,  Mosely,  Beddoes,  and  more  recently  Drs.  Graves 
and  Stokes,  all  agree  in  its  occasional  eflBcacy,  when  sufficiently  per- 
severed in.  Stoll  has  remarked  that  it  is  injurious,  and  Dr.  Dickson  has 
advised  its  discontinuance  when  hectic  symptoms  are  present.  Without 
doubt  like  all  other  remedies,  it  requires  discrimination  ;  in  the  more 
advanced  stages  of  the  disease,  and  indeed,  whenever  great  weakness 
and  emaciation  are  present,  it  would  probably  be  injurious,  and  may 
then  be  advantageously  replaced  by  carriage  exercise,  which  is  fre- 
quently the  only  plan  in  our  power  to  adopt.  The  patient,  says  Dr. 
Graves,  should  be  at  least  from  four  to  five  hours  a  day  in  the  open 
air.  Van-Swieten  was  in  the  habit  of  recommending  his  patients  to 
turn  coachmen. 

On  the  efficacy  oî swinging-  there  is  some  contradictory  evidence, 
but  from  the  testimony  of  Dr.  Currie,  who  tried  it  in  his  own  case 
and  that  of  Dr.  Carmichael  Smyth,  who  wrote  expressly  on  this  sub- 
ject, with  the  more  casual  remarks  of  Themison,  Desault  and  Southey, 
we  may  safely  conclude  that  where  it  agrees  it  may  be  occasionally 
useful.  It  has  a  decided  tendency  to  increase  the  circulation  in  the 
extremities  and  surface  generally,  and  perhaps  to  lower  the  pulse, 
though  this  is  contested  ;  with  children  who  are  naturally  fond  of  the 
exercise,  it  would  be  more  peculiarly  applicable. 

Tvavelling  may  be  safely  recommended  under  certain  circum- 
stances ;  its  influence  upon  the  mind,  the  choice  of  climate  which  it 
affiards,  the  habitual  exposure  to  the  air,  are  amongst  some  of  its  ad- 
vantages. It  is  in  the  early  stages  of  the  disease  only,  and  more 
especially  where  the  symptoms  are  chronic,  that  benefit  may  be  ex- 
pected. The  circumstances  of  the  patient  must  admit  of  every 
comfort,  and  minute  attention  paid  to  other  means  by  which  the  gen- 
eral health  may  be  improved.  Tliere  is  nothing  specific  in  its  influ- 
ence, and  unless  enjoined  with  due  regard  to  the  condition  of  the 
patient,  will  frequently  only  hasten  the  disease. 

In  those  cases  where  the  symptoms  are  more  acute,  the  constitu- 
tion irritable,  the  mucous  membranes  relaxed,  the  cutaneous  func- 
tions impeded,  and  there  is  much  tendency  to  hsemorrhage,  sea 
voyages  have  been  almost  universally  recommended  in  preference  to 
travelling.  In  connection  with  the  voluminous  evidence  we  possess 
ID  favor  of  vomiting  in  the  early  stages  of  phthisis,  the  influence  of 


TREATMENT    OF    PHTHISIS.  499 

moisture,  the  advantages  of  an  equable  temperature,  the  benefit  of 
being  much  in  the  open  air,  the  purity  of  the  atmosphere,  the  robust 
state  of  health  among  those  accustomed  to  a  sea  life,  there  is  every 
reason  to  suppose,  that  when  judiciously  recommended,  sea  voyages 
are  among  our  most  powerful  means  of  arresting  incipient  cases  of 
consumption,  and  merit  still  greater  confidence  in  the  removal  of 
that  state  of  constitution  which  predisposes  to  tubercular  deposition. 
Sailing  or  cruising  for  some  time  would  probably  be  more  advisable 
than  a  long  voyage,  particularly  if  the  patient  has  derived  benefit 
from  the  sickness  ;  and  in  those  cases  where  change  of  climate  is 
recommended  and  much  improvement  has  taken  place  during  the 
voyage,  it  would  be  better  to  repeat  the  latter,  than  hazard  the  doubt- 
ful benefit  of  a  residence  on  land.  The  Atlantic  is  considered  on 
the  whole  as  a  much  more  favorable  climate  than  the  Mediterranean, 
though  this  fact  is  not  satisfactorily  decided,  and  during  the  winter^ 
perhaps  voyages  between  Madeira  and  the  West  Indies  would  be 
among  the  most  favorable.  We  are  inclined,  however,  to  think  that 
voyages  round  our  own  coasts,  and  repeated  at  short  intervals,  would 
at  least  in  incipient  cases,  be  equally  useful,  and  might  certainly  be 
tried  by  a  far  greater  number  of  invalids.  We  can  do  little  more 
than  submit  the  subject  to  the  practitioner's  attention,  referring  him 
to  the  works  of  Reid,  Fothergill,  Gilchrist,  Clarke,  &c.,  for  more 
detailed  information. 

The  real  influence  of  climate  on  consumption  is  beginning  to  be 
far  more  correctly  appreciated,  and  greater  discrimination  shown  in 
the  selection  of  those  cases  where  change  of  climate  is  recommend- 
ed. It  has  been  too  often  considered  as  a  last  resource,  rather  than 
a  means  the  efficacy  of  which  depended  on  its  early  application  ;  and 
in  the  immense  majority  of  cases  which  annually  leave  England  for 
the  advantages  of  a  warmer  temperature,  all  favorable  results  are  not 
only  impossible  on  account  of  the  advanced  stage  of  the  disease,  but 
the  progress  of  the  affection  is  frequently  hastened.  When  ulcera- 
tion has  taken  place,  and  the  general  symptoms  indicate  a  fatal  ter- 
mination, removal  to  a  hot  climate  may  be  regarded  as  decidedly 
injurious,  experience  having  proved  that  under  tliese  circumstances 
the  progress  of  phthisis  is  more  rapid.  It  is  in  the  incipient  stage  of 
the  complaint,  where  the  scrophulous  diathesis  prevails,  where  the 


500  translator's  appendix. 

progress  of  the  disease  is  chronic,  and  the  general  symptoms  not 
prodominant,  that  the  beneficial  effects  of  climate  may  be  expected. 
The  action  of  a  warm  climate  on  the  healthy  frame,  in  exciting  the 
functions  of  the  skin  and  liver  and  diminishing  those  of  the  lungs, 
explains  some  of  the  advantages  to  be  expected  in  pulmonary  affec- 
tions. The  benefit  of  exercise  in  the  open  air  also  points  out  that 
our  selection  should  be  guided  by  other  than  thermometrical  consid- 
erations, and  while  a  mountainous  country  like  Madeira  includes  the 
facility  of  easy  change  of  temperature  by  change  of  elevation,  yet 
where  horse  or  carriage  exercise  is  important,  a  more  level  and  ex- 
tensive country  is  preferable.  A  mild  and  moist  climate  ought  to  be 
preferred,  and  there  are  many  situations  on  the  south  and  western 
coasts  of  England,  which  may  be  resorted  to  with  advantage.  It  has 
been  thought  that  change  of  climate  to  be  effectual  ought  to  be  com- 
plete, and  Avith  this  view  the  East  or  West  Indies,  South  Carolina, 
Florida,  the  Northern  States  of  South  America,  and  more  particularly 
Egypt,  have  been  proposed.  We  can  offer  no  decided  opinion  upon 
the  subject  ;  there  is  every  probability  that  in  some  cases  such  a 
change  would  be  beneficial,  but  the  liability  to  other  diseases  must 
not  be  forgotten,  and  an  accurate  appreciation  of  the  health  and  con- 
stitutional peculiarities  of  the  patient  is  more  peculiarly  necessary. 
In  very  chronic  cases  there  can  be  little  doubt  that  life  may  be  some- 
times prolonged  several  years  by  residence  in  an  equable  mild 
climate.  As  a  general  principle,  it  may  be  safely  admitted,  that  the 
change  from  a  variable  temperature  to  one  of  an  opposite  description, 
when  not  involving  any  serious  diminution  of  the  patient's  comforts, 
is  always  advantageous  ;  and  where  circumstances  render  removal 
impossible,  confinement  to  apartments  of  which  the  heat  is  regulated 
and  the  purity  of  the  air  as  much  as  possible  preserved  during  the 
more  rigorous  weather  of  this  climate,  may  be  judiciously  recom- 
mended, and  indeed  is  often  our  only  resource.  It  must,  however, 
be  recollected  that  this  mode  of  treatment,  being  unfavorable  to  im- 
provement of  the  general  health,  should  only  be  enforced  when  ex- 
posure to  the  air  is  constantly  attended  with  increase  of  the  symptoms. 
It  is  principally  adapted  to  very  delicate  persons,  especially  females, 
to  those  advanced  in  life,  and  to  the  latter  stages  of  the  disease.  We 
must  refer  the  reader  to  Dr.  Clarke's  elaborate  work  ;  it  is  impossible 


TKEATMENT    OF    PHTHISIS.  501 

at  the  present  moment  to  do  more  than  direct  his  attention  to  the 
subject. 

Much  difference  of  opinion  exists  on  the  relative  advantages 
attending  a  residence  on  the  coast  or  inland  for  consumptive  patients. 
It  is  not  in  our  power  to  answer  the  question.  It  would  be  easy  to 
prove  how  imperfectly  the  subject  has  been  studied,  but  we  are  in- 
clined to  think,  from  a  review  of  the  causes  of  phthisis,  that  when 
due  attention  is  paid  to  temperature,  exposure,  and  other  local  con- 
siderations, that  the  sea  coast  on  the  whole  is  preferable. 

Emetics.  —  Though  frequently  prescribed  to  fulfil  temporary  indi- 
cations, they  may  with  great  propriety  be  classed  among  the  reme- 
dies employed  in  the  general  treatment  of  phthisis.  It  would  be 
easy  to  extend  this  article  to  considerable  length,  by  the  simple 
enumeration  of  the  names  of  those  who  have  written  in  favor  of  the 
use  of  emetics  in  a  variety  of  diseases,  and  as  Dr.  Young  says,  it  is 
remarkable  that  a  very  great  majority  of  the  cures  of  consumption 
related  by  different  authors,  have  either  been  performed  by  emetics, 
or  by  decidedly  nauseating  remedies.  Their  systematic  employment 
has  been  more  particularly  recommended  by  Drs.  Morton,  Parr, 
T.  Robinson,  Marryat  and  Reid.  The  latter,  especially,  has  brought 
forward  a  variety  of  valuable  evidence  in  favor  of  the  practice.  Many 
subsequent  authors  have  repeated  the  treatment  he  proposed,  and 
confirmed  his  encomiums  on  the  benefits  of  vomiting  in  phthisis.  It 
is  evident  to  the  most  casual  observer,  that  the  effects  of  vomiting  are 
general,  and  not  confined  to  the  stomach.  The  mechanical  pressure 
upon  the  abdominal  and  thoracic  viscera,  the  influence  upon  the  arte- 
rial and  venous  circulations,  the  effects  upon  the  nervous  system, 
and  the  subsequent  diaphoresis,  all  point  out  that  the  action  of  vomit- 
ing is  general  and  complicated  ;  and,  associated  with  the  benefits 
resulting  from  sea  voyages,  swimming,  &c.,  there  is  every  reason  to 
believe  that  the  use  of  emetics  in  incipient  cases  of  phthisis  is  satis- 
factorily demonstrated.  The  presence  of  gastritis,  inflammatory  or 
congestive  head  symptoms,  hernia,  pregnancy,  &c.,  of  course  contra- 
indicate  their  use.  From  what  we  know  of  the  effects  of  protracted 
sea  sickness,  and  the  history  of  cases  Avhere  emetics  have  been  con- 
tinued several  months,  there  is  no  reason  to  suppose  that  their  con- 


502  translator's  appendix. 

tinued  employment  is  either  necessarily  or  generally  injurious  to  the 
stomach. 

The  tartar  emetic,  ipecacuanha,  sulphate  of  zinc,  and  sulphate  of 
copper,  either  singly  or  combined,  have  been  usually  employed. 
When  a  simple  tonic  and  derivative  effect  is  desired,  the  sulphate 
of  zinc  alone,  or  in  solution  with  alum,  as  Dr.  Mosely  recom- 
mends, should  be  preferred,  (sul.  zin.,  ^nj.;  alum,  3J.;  aq.  Oj.), 
but  in  proportion  as  we  wish  to  allay  febrile  symptoms,  the  tartar 
emetic  and  ipecacuanha,  in  conjunction  or  singly,  are  most  effectual. 
Violent  and  continued  vomiting  must  be  avoided  ;  the  smallest  doses, 
as  a  general  rule,  are  best.  And  we  must  particularly  guard  against 
exciting  diarrhœa.  The  morning  has  generally  been  considered  the 
best  time  for  their  administration,  though  when  rigors  come  on  at 
any  particular  period  of  the  day,  the  well  known  action  of  an  emetic 
in  the  cold  stage  of  intermittent  fever,  would  render  their  trial  at  this 
period  advisable.  When  repeated  at  night  they  have  allayed  the 
hectic  symptoms,  and  promnted  sleep.  Their  administration  re- 
qtiires  discrimination,  and  they  should  only  be  persisted  in  when 
their  effects  are  evidently  favorable.  Dr.  Marryat  in  his  "Thera- 
peutics," prescribes  one  grain  of  tartar  emetic  with  three  of  ipecac- 
uanha, to  be  taken  two  or  three  times  a  week  in  the  morning,  fasting. 
Mr.  Adair  (Vide  Med.  Comm.  vol.  xviii.,  page  473.  1791),  orders  a 
grain  of  the  sulphate  of  copper,  with  a  drop  of  sulphuric  acid,  in  half 
an  ounce  of  water,  to  be  preceded  by  a  pint  of  warm  water,  and  re- 
peated three  alternate  evenings,  and  afterwards  daily,  every  morning. 
Dr.  Senter  (Trans.  Coll.  Phys.  vol.  i.  Philad.  1793),  gives  a  dry 
vomit  of  from  seven  to  ten  grains  of  sulphate  of  copper  and  ipecacu- 
anha, to  be  taken  fasting  every  second  or  third  morning.  Dr.  Reid 
found  that  five  grains  of  ipecacuanha  were  sufficient  to  begin  with. 
The  preparations  of  emetine  might  be  tried,  particularly  with  chil- 
dren. We  shall  conclude  our  remarks  on  emetics  by  observing  that 
their  therapeutical  employment  in  phthisis,  and  their  influence  on 
the  health  generally,  are  considerations  of  great  interest  and  im- 
portance.* 

*  We  are  gratilied  to  find  that  our  conclusions  on  the  importance  of 
emetics  are  confirmed  by  Dr.  Clarke  in  his  admirable  section  on  this  subject 


TREATMENT    OF    PHTHISIS.  503 

It  may,  we  think,  be  safely  advanced  as  a  general  principle  in  the 
treatment  of  disease,  and  more  particularly  of  constitutional  disease, 
that  our  measures  should  be  principally  directed  to  those  organs  and 
tissues  of  the  body  which  are  least  liable  to  be  involved  in  the 
natural  progress  of  the  affection,  and,  consequently,  in  the  treatment 
of  phthisis,  we  should  not  attempt  its  cure  by  acting  on  the  digestive 
mucous  membranes,  but  on  the  cutaneous  and  urinary  organs  which 
are  so  seldom  organically  affected. 

The  use  of  baths  in  a  variety  of  forms  with  dry  or  moist  and  stimu- 
lating frictions  on  the  skin,  are  almost  invariably  included  in  the 
treatment  prescribed  by  different  authors.  The  mutual  influence  of 
the  pulmonary  and  cutaneous  functions  is  sufficiently  established, 
and  the  importance  of  the  latter  too  evident  to  need  illustration.  Dn 
Armstrong,  in  his  valuable  essay  on  consumption  (page  213),  says, 
"If  we  go  more  minutely  into  this  subject,  we  shall  find  that  many 
diseases  of  the  skin  are  incompatible  with  those  of  the  lungs  ;  hence 
in  Great  Britain,  those  persons  afflicted  with  cutaneous  eruptions,  ar& 
the  least  exposed  to  pulmonary  consumption  :  but  let  that  disease  be 
incautiously  cured,  and  they  often  fall  victims  to  suppuration  in  the 
lungs,  as  I  well  know  from  personal  observation."  "  I  have  seen,^ 
says  the  same  author,  "coughs  of  a  phthisical  tendency  disappear  on 
the  coming  out  of  a  spontaneous  eruption  of  the  skin  ;  and  I  have 
seen  a  similar  effect  from  pimples  artificially  induced  on  the  surface 
by  irritating  ungent  ;  the  connexion  between  phthisis  and  the  skin 

(Vide  Cycl.  Pract.  Med.  Part  xxiii.  page  342.)  That  distinguished  writer 
coinciding  with  Dr.  Carswell's  ingenious  views  relative  to  the  cause  of  the 
peculiar  locality  of  tubercular  deposition  in  the  lungs  and  elsewhere  (Vide 
Article  "  Tubercle")  says,  "  we  can  easily  conceive  how  the  repeated  ac- 
tion of  emetics  may  prevent  the  deposition,  or  at  least  the  accumulation  of 
tuberculous  matter  in  the  bronchial  ramifications  and  air-cells,  and  thus  pre- 
vent the  localization  of  the  disease,  and  give  time  for  the  correction  of  the 
constitutional  disorder.  In  this  manner,  it  is  not  improbable  that  a  judi- 
cious use  of  emetics  may  prove  a  powerful  means  of  preventing  the  déposi- 
tion of  tuberculous  matter  in  the  lungs."  The  same  author  refers  to  the 
powerful  and  recent  evidence  of  Dr.  Giovanni  de  Vittis,  in  favor  of  the  use 
of  emetics  in  phthisis  and  chronic  catarrh.  Vide  Annali  Universali  di 
Jkledicina.    December,  1832.  —  Cowa.n. 


504  translator's  appendix. 

appears  to  me  a  subject  of  vast  importance  in  a  practical  and  patho- 
logical point  of  view." 

In  the  treatise  of  the  late  Dr.  Kentish  on  the  employment  of  baths, 
there  are  some  striking  cases  of  severe  pulmonary  affections  success- 
fully treated  by  the  common  vapor  or  sulphur-vapor  bath.  In  one 
example  of  apparent  phtliisis  the  latter  was  taken  every  other  day 
during  four  months  with  ultimate  success  and  gradual  increase  of  the 
general  strength.  To  be  effectual,  baths  must  be  persevered  in,  and 
much  care  taken  by  the  use  of  diluents,  friction  and  exercise,  to  avoid 
their  injurious  effects.  The  temperature  should  be  regulated,  and 
the  stimulating  nature  of  the  bath  adapted  to  the  peculiarities  of  the 
patient's  constitution.  In  scrophulous  and  chronic  cases,  much  ben- 
efit may  be  expected  from  this  mode  of  treatment,  and  in  opposite 
circumstances  their  judicious  employment  will  at  least  prove  a  valua- 
ble palliative  remedy.  The  hot  air  bath,  proposed  in  1819,  by  Dr. 
Gower,  and  since  modified,  is  powerfully  diaphoretic  and  a  convenient 
application. 

Counter  irritatioji  in  the  treatment  of  phthisis  has  the  testimony  of 
almost  every  ancient  and  modern  author  in  its  favor.  The  theory  of 
its  action  is  far  less  important  than  the  inquiry,  if  experience  has 
satisfactorily  demonstrated  its  utility  ;  all  we  can  say  is,  that  there 
are  few  subjects  in  therapeutics  on  which  so  little  discordance  of 
opinion  has  existed.  Every  gradation  of  irritation  from  simple  rube- 
faction  to  the  actual  cautery  has  been  recommended,  and  evidence 
in  favor  of  all  has  been  adduced.  The  revulsive  treatment  so  much 
insisted  upon  by  the  ancients,  seems  reviving  in  modern  practice. 
In  its  application  to  phthisis  we  may  admit,  as  a  general  rule,  that  it 
should  be  avoided  when  much  febrile  excitement  is  present,  or  at 
least  be  deferred  until  this  has  been  subdued.  It  should  be  propor- 
tionably  deep  and  permanent  in  its  character  as  the  disease  is  chronic 
and  the  lymphatic  temperament  predominates,  and  wlienever  it  pro- 
duces great  general  irritation,  pain,  loss  of  sleep,  &c.,  its  mode  of  ap- 
plication should  be  varied,  or  if  this  is  insufficient,  it  must  be  wholly 
relinquished.  With  attention  to  these  general  principles,  it  may  be 
regarded  as  eminently  useful  in  all  chronic  thoracic  affections  ;  when 
supported  by  the  patient,  it  should  never  be  omitted  in  the  treatment 
of  phthisis,  though  in  all  acute  cases  it  must  follow  the  use  of  anti- 


TREATMENT    OF    PHTHISIS,  505 

phlogistic  measures.  A  variety  of  stimulating  lotions,  containing 
vinegar,  alcohol  and  ammonia,  have  been  proposed  by  Drs.  Scuda- 
more,  Hall,  and  others,  and  perhaps  may  be  always  safely  recom- 
mended with  some  slight  modifications  as  to  temperature.  They 
inci-ease  the  circulation  on  the  surface  of  the  chest,  and  render  the 
skin  less  easily  affected  by  atmospheric  changes.  They  are  gene- 
rally advised  to  be  used  in  the  morning,  and  repeated  once  or  twice 
during  the  day.  Dr.  Hall  recommends  the  more  powerful  and  per- 
manent action  of  a  pad  steeped  in  alcohol.  Blisters,  either  frequently 
repeated  or  caused  to  suppurate,  are  among  the  most  general  means 
resorted  to  for  counter  irritation.  They  may  perhaps  be  regarded  as 
best  adapted  for  incipient  threatening  cases,  and  for  the  treatment  of 
those  incidental  complications  so  frequently  occurring  during  the 
progress  of  the  principal  affection.  They  may  also  be  occasionally 
conjoined  with  the  use  of  setons,  issues,  tartar  emetic  ointment,  or 
other  means  by  which  a  suppurative  process  is  established.  As  our 
object  in  the  employment  of  blisters  in  phthisis  is  local  irritation,  and 
the  avoidance  of  any  general  re-action  always  desirable,  Dr.  Thomp- 
son (Vide  Mat.  Med.  t.  ii.,  page  548)  says,  this  may  be  effected  by 
moistening  the  skin  with  water,  and  passing  a  piece  of  nitrate  of  silver 
lightly  over  it,  so  as  to  include  the  whole  of  the  moistened  surface. 
The  action  is  rapid,  effectual,  and  purely  local.  Dr.  Thompson 
strongly  recommends  it  where  much  febrile  excitement  and  constitu- 
tional irritability  are  to  be  dreaded.  Intense  pain  and  slough  result 
from  an  excess  of  the  nitrate  of  silver.  Dr.  Scudamore,  with  the 
same  intention,  speaks  highly  of  a  saturated  infusion  of  cantharides 
in  strong  acetic  acid,  applied  to  the  skin  by  means  of  a  camel's  hair 
brush. 

p  The  tartar  emetic  ointment,  or  a  strong  solution  of  this  salt  (Thomp- 
son) applied  hot  to  the  previously  frictioned  skin,  either  alone,  or  in 
severe  cases,  conjointly  with  setons  or  issues  under  the  clavicles,  or 
between  the  shoulders,  may  be  regarded  as  the  least  painful,  and 
most  effectual  means  of  counter  irritation.  Croton  oil,  ammonia,  and 
a  variety  of  irritating  liniments  may  be  occasionally  useful  ;  the  ac- 
tion of  the  former  is  mild  and  easily  supported. 

In  proportion  as  humoral  pathology  prevailed,  our  derivative  meas- 
p  3 


506  translator's  appendix. 

ures  receded  from  the  disease  they  were  intended  to  remove;  at 
present,  however,  it  is  generally  admitted,  that  it  is  better  to  apply 
our  remedies  as  near  as  possible  to  the  affected  organ,  and  the  sub- 
clavicular regions  are  considered  the  best  points  for  establishing  per- 
manent counter  irritation.  Dr.  Graves  invariably  places  two  setons 
beneath  the  clavicle  in  all  incipient  cases,  and  advises  their  employ- 
ment at  the  age  of  puberty,  whenever  phthisis  may  be  apprehended. 
It  may  perhaps  be  useful  to  let  old  wounds  occasionally  heal  and 
form  new  ones,  for  it  is  probable  they  become  less  effectual  after  the 
constitution  is  habituated  to  their  presence. 

Bleeding.  —  "  Super  onmia  vero  venesectione,  eaque  satis  tempes- 
tive,  frequenter,  et  copiosé  adhibitâ,  ut  malicentus,  et  tabidus  fuerit 
ËBger,"  says  Morton,  and  perhaps  there  are  few  diseases  in  which 
bleeding  has  been  more  generally  prescribed,  or  more  frequently 
repeated.  The  buffy  appearance  of  the  blood  so  usual  in  phthisis, 
has  been  erroneously  considered  as  a  justifying  indication  for  the  use 
of  the  lancet;  in  the  present  state  of  our  knowledge  this  symptom 
alone  is  quite  insufficient,  since  we  well  know  that  mercury,  preg- 
nancy, exercise,  &c.,  are  capable  of  producing  this  peculiar  condition 
of  the  circulating  fluid.  It  has,  we  think,  been  'demonstrated  in  the 
course  of  this  volume,  that  phthisis,  in  its  origin  or  causes,  is  not  an 
inflammatory  disease  ;  and,  that  in  all  its  subsequent  stages,  inflam- 
mation is  usually  the  result  of  tubercular  deposition,  or  in  those  cases 
where  it  precedes  the  latter,  an  accidental  complication  which  has- 
tens its  development.  These  are  not  to  be  regarded  as  theoretical 
views,  but  the  ultimate  expression  of  numerous  and  analysed  facts  ; 
on  their  reception  or  rejection,  will  the  practitioner's  reliance  on  the 
efficacy  of  bleeding,  as  part  of  the  general  treatment  of  phthisis,  ma- 
terially depend.  It  must  not  be  supposed  that  antiphlogistics  are  to 
be  excluded  from  tha  therapeutics  of  consumption  ;  if  inflammation 
is  not  a  cause,  it  is  a  very  frequent  complication,  and  adopting 
means  for  its  prevention  and  removal,  forms  a  leading  indication  in 
the  treatment  of  this  affection.  To  protect  the  individual  and  the 
affected  organ  from  the  influence  of  all  those  agents,  internal  and  ex- 
ternal, which  tend  to  create  an  inordinate  degree  of  excitement,  or 
favor  the  development  of  active  congestion,  may  be  regarded  as  one 
of  the  most  important  practical  rulca.   It  is  tlic  opinion  which  regards 


TREATMENT    OF    PHTHISIS.  507 

inflammation  as  the  source  of  all  the  evil,  and  considers  the  removal 
of  it  as  the  only,  or  principal  means  of  preventing  the  progress  of  the 
disease  that  we  are  now  combatting. 

After  reflecting  on  the  pathology  of  phthisis,  its  nature,  its  causes, 
and  the  general  character  of  the  remedies  Avhich  have  been  most 
successful  in  its  cure  or  palliation,  and  after  having  compared  the 
conflicting  evidence  of  a  variety  of  authors  on  the  subject,  we  think 
that  bleeding  should  be  regulated  by  precisely  the  same  principles 
in  consumption,  as  in  any  other  disease,  and  ought  never  to  be  prac- 
tised without  the  presence  of  those  indications  which  guide  us  in  the 
employment  of  venesection  in  general.  The  practitioner  should 
never  forget  the  chronic  nature  of  the  disease,  the  impossibility  of 
curing  it  rapidly,  the  subsequent  debility,  and  the  importance  of  be- 
ing governed  in  the  abstraction  of  blood,  by  the  state  of  the  digestive 
organs.  It  is  more  particularly  in  the  early  stages,  when  the  heat, 
pulse,  cough,  and  dyspnoea  indicate  inflammatory  action,  that  bleed- 
ing will  be  useful,  and  may  occasionally  be  repeated  with  advantage. 
Small  revulsive  bleedings  of  a  few  ounces  will  often  aflTord  relief  to 
the  thoracic  and  hectic  symptoms.  The  application  of  leeches 
under  the  clavicles  has  been  recently  recommended  in  the  early 
stages  of  the  complaint  ;  of  tlieir  real  eflicacy  we  are  unable  to 
speak  with  certainty  ;  we  have  seen  them  tried  by  M.  Louis  without 
any  evident  success.  Local  bleeding  in  the  form  of  cupping  is  also 
frequently  indicated  against  the  intercurrent  inflammatory  complica- 
tions. Were  we  to  choose  between  the  indiscriminate  use  of  the 
lancet  or  its  rejection  in  phthisis,  we  believe  the  latter  would  be  less 
prejudicial. 

Stahl,  Dover,  Van-Swieten,  Watt,  and  Stoll,  are  among  the  most 
strenuous  advocates  of  general  and  repeated  bleedings.  They  are 
objected  to  by  Marryat,  Heberden,  Reid  and  others. 

Mercurials.  —  In  the  supposed  analogy  between  phthisis  and  scro- 
phula,  and  in  the  doctrines  of  hepatic  and  syphilitic  consumptions, 
we  may  trace  the  reason  of  the  frequent  employment  of  mercury. 
It  has  been  more  particularly  recommended  for  the  cure  of  phthisis 
by  Drs.  Rush,  Stev/art  and  Physic,  who  have  strongly  advocated  the 
tonic  treatment  in  conjunction  with  salivation.  Mr.  Watt,  in  his 
cases  of  diabetes  and  consumption,   published  in  1808,  also  advises 


508         translator's  appendix. 

salivation  after  the.  singular  preliminary  treatment  of  repeated  bleed- 
ino-s  to  induce  febrile  re-action  ;  his  avowed  object  was  to  modify 
the  blood.  By  the  majority  of  authors  its  use  has  been  confined  to 
particular  indications  occurring  in  the  earlier  stages  of  the  disease, 
to  scrophulous  habits,  to  cases  of  mesenteric  affection,  hepatic  ob- 
structions, and  its  action  as  a  mild  purgative.  The  greater  number 
of  modern  authors  regard  its  habitual  administration  in  phthisis  as 
decidedly  injurious.  From  what  we  know  of  its  general  action  upon 
the  frame,  the  irritable  state  of  the  nervous  system  which  it  induces, 
the  increased  susceptibility  to  external  influences,  the  febrile  excite- 
ment, and  the  necessary  interruption  to  other  indications,  there  seems 
no  reason  to  call  in  question  the  propriety  of  this  opinion  as  a  gen- 
eral rule  ;  and  if  in  the  use  of  mercurials  we  include  the  production 
of  its  ordinary  constitutional  effects,  there  is  still  greater  reason  to 
erase  it  from  the  list  of  therapeutics  for  phthisis.  We  are,  however, 
inclined  to  believe  that  its  good  and  bad  effects  have  been  greatly 
exaggerated,  the  former  being  frequently  founded  on  erroneous  diag- 
nosis, the  latter  on  its  abuse. 

There  can  be  no  doubt  that  in  scrophulous  phlegmatic  habits,  and 
in  various  derangements  of  the  digestive  tube,  that  it  forms  one  of 
our  most  valuable  remedies,  and  the  researches  of  Dr.  W.  Philip  on 
the  employment  of  small  doses  of  mercury,  exhibit  the  action  of  this 
agent  in  a  new  light,  and  prove  that  we  have  hitherto  been  ignorant 
of  the  means  by  which  its  real  efficacy  in  chronic  diseases  may  be 
obtained,  and  its  injurious  effects  avoided. 

The  evidence  relative  to  the  influence  of  mercurial  vapors  is  too 
contradictory  to  allow  of  any  positive  conclusion,  and  the  arguments 
against  the  use  of  mercury,  founded  upon  the  experiments  of  Dr. 
Clayton,  in  1694,  Dr.  Saunders,  in  1793,  and  more  recently  those  of 
M.  Cruveilhier,  consisting  of  the  injection  of  mercury  into  the  veins 
of  dogs,  and  the  apparent  production  of  tubercles  in  the  lungs,  can- 
not be  admitted  as  of  any  value,  since  there  is  no  doubt  that  in  all 
these  instances  the  mercury  was  simply  deposited  in  the  pulmonary 
tissue,  where  it  produced  suppuration  like  any  other  foreign  body. 

The  expressed  juice  or  extract  of  taraxacum  has  been  favorably 
mentioned  as  an  alterative  in  tuberculous  constitutions,  by  Hufe- 


TREATMENT    OF    PHTHISIS. 


509 


land,  Zimmermann,  Kaemp,  and  its  utility  is  acknowledged  by  mod- 
ern practitioners. 

The  sarsaparilla,  the  muriate  of  lime  and  of  baryta,  and  more 
especially  the  mineral  waters,  are  also  deserving  of  increased  at- 
tention. 

Digitalis.  —  Since  its  diuretic  powers  were  so  successfully  demon- 
strated by  Dr.  Withering,  in  1785,  digitalis  has  been  alternately 
extolled  as  a  cure,  or  condemned  as  injurious'  in  the  treatment  of 
phthisis.  Reid  thinks  it  a  stimulant  ;  Saunders,  a  tonic  ;  Dr.  Hamil- 
ton, a  direct  sedative  ;  Kinglake,  a  narcotic  stimulant  ;  Magennis,  that 
it  acts  by  extinction  of  morbid  action  ;  Beddoes,  that  its  efficacy  in 
consumption  is  equal  to  that  of  bark  in  intermittents,  &c.  &c.  ;  from 
all  these  satisfactory  conclusions,  the  reader  may  infer  that  it  really 
has  some  active  properties,  and  that  its  action  varies  with  the  circum- 
stances under  which  it  is  administered.  It  is  now  very  rationally 
almost  entirely  rejected  as  a  cure  for  consumption,  and  merits  only 
to  be  regarded  as  one  of  the  many  means  occasionally  useful  in  this 
disease,  and  which  may  sometimes  assist  the  operation  of  more  im- 
portant measures.  It  seems  principally  adapted  to  phlegmatic  habits, 
after  depletion,  and  especially  where  there  is  any  anasarcous  ten- 
dency. The  state  of  the  digestive  tube  must  be  previously  ascer- 
tained, and  from  its  effects  accumulating  it  requires  to  be  very  closely 
watched. 

Prussic  Acid.  —  This  has  quite  as  little  claims  to  be  regarded  as  a 
specific  for  phthisis  as  the  former.  Its  action  is  more  undoubtedly 
sedative,  and  it  may  be  often  prescribed  with  advantage  against  the 
cough,  particularly  in  the  early  stages,  when  the  system  is  irritable 
and  any  spasmodic  symptoms  are  present.  It  may  be  considered  as 
more  adapted  to  hectic  than  digitalis,  and  often  tends  to  allay  sick- 
ness, epigastric  pain,  and  pyrosis.  Dr.  Thompson  speaks  highly  of 
its  use  in  laryngeal  affections,  and  in  phthisis  it  may  be  regarded  as 
a  useful  and  palliative  remedy. 

The  discovery  of  any  means  by  which  a  sedative  influence  might 
be  procured,  and  the  cough  moderated,  without  any  injurious  secon- 
dary effects  resulting,  would  be  a  valuable  addition  to  the  thera- 
peutics of  phthisis.  Dr.  RoUo  recommended  the  hepatized  or  hydro- 
sulphuret  of  ammonia,  on  a  theory  of  its   chemical  action.    It  has 


510  translator's  appendix. 

since  been  mentioned  by  Dr.  Armstrong,  and  more  recently  by  Dr. 
Newton,  in  the  second  number  of  the  Dublin  Medical  Journal.  The 
latter  gentleman,  in  conjunction  with  Dr.  Marsh,  found  that  it  lower- 
ed the  pulse,  increased  the  appetite,  promoted  the  urinary  secretion, 
and  acted  powerfully  on  the  skin.  These  properties  give  it  claims 
to  the  practitioner's  attention  as  a  palliative  remedy  for  phthisis,  and 
we  hope  some  judicious  trial  of  its  real  efficacy  will  be  made.  The 
dose  mentioned  is,  three  drops  three  times  a  day,  in  a  tumbler  of 
water.  We  may  gradually  increase  this  quantity  to  thirty  or  forty 
drops.     Nausea,  headache,  and  vertigo  result  from  an  overdose. 

From  what  we  know  of  the  action  of  alkalies  upon  the  system, 
their  solvent  power,  and  general  adaptation  to  febrile  symptoms,  at 
least  in  the  earlier  stages  of  disease,  there  is  every  inducement  to 
continue  our  investigations  on  the  subject,  and  we  think  their  appli- 
cation to  phthisis,  on  these  and  other  grounds,  well  worth  the  prac- 
titioner's attention.  We  have  no  facts  to  bring  forward,  and  shall 
therefore  refer  the  reader  to  Dr.  Burrows' s  very  interesting  and  tal- 
ented lectures,  published  in  the  Medical  Gazette,  page  711.  1834. 

Iodine  has  not,  we  think,  received  the  attention  it  deserves  as  a 
remedy  in  phthisis.  Its  well  known  action  in  scrophula,  goitre, 
visceral  engorgements  (particularly  those  of  the  liver),  demonstrate 
its  powerful  influence  upon  the  absorbent  system  ;  and  the  evidence 
of  Drs.  Baron,  Gairdner  and  others,  on  its  employment  in  consump- 
tion, amply  justify  its  continual  trial  in  this  disease.  It  is  almost 
unnecessary  to  remark,  that  so  active  a  remedy  requires  great  care 
and  discrimination,  but  from  the  statements  of  M.  Zinck,  of  Lausanne, 
(Vide  Journal  Complémentaire,  April  and  May,  1824),  it  is  probable 
that  its  injurious  effects  have  been  exaggerated.  Its  association  with 
soda  in  the  blood  makes  Dr.  Burrows  suppose  it  possesses  a  solvent 
power.  Scrophulous  phlegmatic  habits,  the  absence  of  febrile  ex- 
citement, and  a  healthy  state  of  the  digestive  tube  are  the  most  favor- 
able conditions  for  its  administration.  Its  influence  upon  the  stomach 
may  be  avoided,  by  prescribing  it  in  the  form  of  inhalation  to  which 
we  shall  presently  refer.  Its  diuretic  and  emmenagogue  powers 
give  it  additional  claims  to  our  notice.  Some  objections  to  its  em- 
ployment in  phthisis  have  been  advanced  by  Laennec,  MM.  Laennec 
and  Récamier  (Vide  Revue  Med.,  June,  1825)  ;  they  only  prove  what 


TREATMENT    OF    PHTHISIS,  511 

our  knowledge  of  the  drug  would  at  once  indicate  to  every  judicious 
practitioner,  that  it  is  not  universally  applicable.* 

Bark.  — This  has  also  enjoyed  the  reputation  of  possessing  specific 
properties  in  the  cure  of  phthisis.  The  opinion  has  been  principally 
supported  by  Morton,  De  Metternich  and  Sedillot,  while  by  other 
authors  it  has  only  been  prescribed  to  answer  particular  indications. 
Mead  advises  it  before,  and  Heberden  after  ulceration  has  taken 
place  ;  Dickson  limits  it  to  hsemoptysis  ;  Fothergill  to  the  latter 
stages  of  the  disease  ;  and  Bayle  seems  to  regard  it  solely  as  an  anti- 
periodic.  A  variety  of  evidence  is  in  short  adduced  in  favor  ot 
equally  variable  opinions  ;  we  may  therefore  conclude  that  bark  must 
be  prescribed  on  the  same  general  principles  which  indicate  its  em- 
ployment in  other  chronic  diseases,  and  that  it  has  no  claims  to  the 
character  of  a  specific  for  phthisis.  The  combination  of  bark  and 
steel,  bark  and  sulphur,  as  advised  by  Drs.  Trotter  and  Sims  in  scrO' 
phulous  cases,  seems  to  have  been  very  successful. 

The  partiality  displayed  by  authors  to  particular  remedies  renders 
the  opinion  of  any  single  individual  of  comparatively  little  impor- 
tance, but  by  comparing  the  treatment  pursued  by  numerous  prac- 
titioners under  similar  circumstances,  we  can  occasionally  discover 
some  point  on  which  they  are  more  or  less  unanimous,  and  thus  in- 
crease the  probabilities  in  favor  of  the  efficacy  of  any  particular  rem- 
edy. One  of  the  most  popular,  as  applicable  to  phthisis  and  chest 
affections  generally,  is  sulphur.  Its  virtues  are  highly  extolled  by 
Galen,  Sylvius,  Willis,  Lieutand,  Sydenham,  Stahl,  Hoffman,  and 
many  others,  and  from  its  special  and  powerful  action  on  the  cuta- 
neous surface,  its  internal  use,  in  a  disease  like  phthisis,  has  perhaps 
been  too  much  neglected.     As   a  remedy  for  costiveness  in  this 

*  In  a  recent  work  by  Dr.  Morton,  of  Philadelphia,  entitled  Elustrations 
of  Pulmonary  Consumption,  Sfc,  the  efficacy  of  iodine  in  phthisis  is  sup- 
ported upon  an  extensive  practical  observation  of  its  effects.  He  prescribes 
the  iodine  in  the  form  of  a  solution  containing  three  grains  of  iodine,  and  six 
grains  of  hydryodate  of  potash  in  an  ounce  of  distilled  water,  from  three  to 
fiye  drops  of  which  are 'given  every  morning,  noon  and  night.  We  have 
not  ourselves  seen  the  work,  but  quote  from  Dr.  Clarke's  notice  respecting 
it.  —  Cowan  . 


512 


TRANSLATOR  s    APPENDIX. 


affection,  it  is  worthy  of  notice,  and  might  perhaps  be  advantageously 
employed  against  profuse  perspirations.  Its  forming  a  constituent 
portion  of  the  nervous  system,  and  its  general  absorption  when  taken 
internally,  proved  by  its  presence  in  the  perspiration,  &c.,  are  suffi- 
cient reasons  to  make  us  suppose  that  it  may  at  least  be  occasionally 
useful.  Its  most  effectual  exhibition  is  probably  in  the  form  of  min- 
eral waters.  Of  the  utility  of  its  external  application,  there  can  be 
no  doubt,  and  in  the  form  of  inhalation  it  is  far  from  being  inert. 

A  variety  of  other  remedies,  such  as  myrrh,  iron,  preparations  of 
lead,  &c.,  have  been  favorably  mentioned  in  connexion  Avith  con- 
sumption, but  since  they  have  not  been  regarded  as  peculiarly  ap- 
plicable to  this  disease,  we  think  it  quite  unnecessary  to  refer  to 
them. 

We  shall  now  make  a  few  remarks  on  the  local  remedies  which 
have  been  proposed,  and  direct  the  reader's  attention  to  the  method 
of  fumigation  or  inhalation.  The  application  of  medicated  vapors  to 
thoracic  affections,  may  be  traced  back  as  far  as  the  writing  of  Galen, 
who  speaks  highly  of  the  vapors  from  experiment.  These  were  also 
recommended  by  Rhazes  (an  Arabian  physician),  and  Bennet,  who 
prescribed  them  in  conjunction  with  some  of  the  balsamic  remedies. 
The  latter  writer  especially,  has  insisted  upon  the  use  of  fumigation, 
invented  an  apparatus  for  their  administration,  and  was  also  in  the 
habit  of  employing  the  vapors  from  a  variety  of  infused  herbs.  Dr. 
Pearson  and  others  have  spoken  of  the  utility  of  aether,  and  the  former 
prescribed  the  inhalation  of  narcotic  vapors,  arising  from  the  macera- 
tion of  9j.,  5j.,  of  the  leaves  of  hyoscyamus  in  ^j.  of  asther.  Dr. 
Mead,  who  does  not  appear  himself  to  have  pursued  the  treatment, 
thinks  the  fumigations,  as  described  by  Bennet,  were  too  much  neg- 
lected. 

It  will  be  easily  gathered  from  these  slight  references,  that  the 
methods  proposed  by  more  recent  authors,  have  no  other  claims  to 
novelty  than  the  use  of  agents  with  which  our  predecessors  were  un- 
acquainted. Their  real  value  is  not,  however,  on  this  account 
diminished,  and  after  an  examination  of  the  works  of  Gannel,*  Mur- 

*  Two  Memoirs  on  the  Inhalations  of  Chlorine,  &c.  Translated  by  W. 
H.  Potter,  M.  R.  I.  8vo.  London,  1830.  — Cowan. 


TREATMENT    OF    PHTHISIS.  513 

ray,*  Scudamore.-f-  and  Cottereau,|  we  do  not  hesitate  to  say,  that  the 
evidence  in  favor  of  the  palliative   effects   of  chlorine  and  iodine  in 
phthisis,  is  amply  sufficient  to  encourage  others  in  the  application  of 
these  remedies.     The  cases  related  by  M.  Cottereau  are  by  far  the 
most  satisfactory  ;  we  would  refer  to  the  first,  also  published  by  Gan- 
nal,  and  to  the  twelfth,  as  particularly  striking  and  decisive  as  to  the 
existence  of  pulmonary  tubercles.     Sir  C.  Scudamore  insists  strongly 
on  the   power  of  iodine  in  facilitating  expectoration,  diminishing 
cough,  and  promoting   sleep  and  appetite.     Dr.  Thompson,  in  his 
Mat.  Med.,  speaks  very  favorably  of  the  palliative  action  of  chlorine 
in  phthisis.     All  his  trials  were  upon  advanced  cases  ;  though  not 
ultimately  successful,  it  invariably  gave  relief,  and,   as  he  expresses 
himself,  may  be  said  to  have  scattered  flowers  on  the  borders  of  the 
grave.     It  is  but  fair  to  state,  that  Dr.  Stokes  of  Dublin,  M.  A.  Laen- 
nec,  of  Nantes,  M.  Joulmouche,  of  Rennes,  and  M.  M.  Flandin  and 
Mi-quel,   of  Paris,  have   administered  chlorine   inhalations  without 
success,  and  occasionally  have  found  them  injurious.     The  utility  of 
these  and  other  vapors  of  the  narcotic  class,   as  particularly  recom- 
mended by  Dr.  Scudamore  in   chronic  bronchitis   and  various  other 
affections  included  under  the  general  term  asthma,  is  more  satisfac- 
torily demonstrated,  and  may  tend  to  point  out  those  cases  of  con- 
sumption where  peculiar  benefit  may  be  expected  from  their  employ- 
ment.    Whatever  may  be  the  result  with  regard  to  their  sanative 
influence  in  this  disease,  they  may  be  considered  as  forming  valuable 
adjuncts  to  the  therapeutics  of  thoracic  affections.     How  far  their 
beneficial  effects  are  depending  on  their  local  action,  it  is  rather  diffi- 
cult to  determine  ;  but  from  the  absorbing  power  of  the  bronchial 
membrane,  and  the  active  nature  of  the  agents  employed,  it  is  more 
than  probable,  that  much  may  be  ascribed  to  their  general  influence, 

*  Inhalation  of  Iodine,  Sfc,  J.  Murray,  M.  D.     London,  1829. 

t  Inhalation  in  Pulmonary  Consumption,  fyc.     By  Sir  C.  Scudamore, 
M.  D.,  F.  R.  S.     8vo.  London. 

X  Mémoire  by  Cottereau.  —  Arch.  Gen.  de  .Med.     November,  1830. — 
R   3 


514  -     translator's  appendix. 

which  has   the  advantage  of  being  produced  without  injury  to  the 
gastric  mucous  membrane. 

The  vapors  of  boilmg  tar  have  been  highly  extolled  by  Dr.  Crich- 
ton  and  others.  The  experience  of  Dr.  Forbes  leads  to  a  less  favor- 
able conclusi.m  ;  but  Dr.  Morton,  in  the  work  already  alluded  to, 
says,  that  among  the  various  substances  which  he  has  tried,  there  is 
no  one  which  he  has  prescribed  with  equal  success  to  tar.  In 
chronic  catarrh  he  knows  of  no  plan  of  treatment  that  can  vie  with 
this.  (Vide  Op.  C{<,  page  511.)  Sulphurous  fumes  have  also  been 
recommended,  as  well  as  diffusing  a  variety  of  vapors  in  the  apart- 
ment of  the  patient  ;  on  their  beneficial  or  injurious  effects  we  are 
unable  to  speak. 

We  cannot  close  these  remarks,  without  insisting  upon  the  neces- 
sity of  strict  attention  to  accuracy  of  diagnosis  and  clear  discrimina- 
tion of  the  peculiar  circumstances  under  which  our  remedies  are 
applied.  Without  this  our  facts  cannot  be  available  to  others,  and 
from  want  of  attention  to  these  important  data,  by  far  the  greater 
portion  of  the  details  to  Avhich  we  have  alluded,  is  utterly  incapable 
of  leading  to  any  positive  results.  The  difficulty  of  the  inquiry  is 
immense,  and  much  caution  must  be  shown  in  arriving  at  general 
conclusions  ;  on  the  other  hand,  the  hopelessness  of  the  disease,  the 
inefficiency  of  every  known  treatment,  fully  justify  experiments  in 
search  of  a  new  remedy,  and  it  is  not  irrational  to  suppose  that  so 
great  a  desideratum  may  be  found  in  a  class  of  substances  which, 
while  they  exert  a  general  influence  upon  the  health,  are  capable  of 
being  directly  applied  to  the  diseased  organ. 

After  thus  expressing  our  convictions,  we  leave  the  subject  to  the 
judgment  of  the  reader  and  to  the  decision  of  future  investigation  ; 
we  shall  now  briefly  advert  to  the  pneumatic  method.  This  is  evi- 
dently but  a  varied  application  of  the  preceding,  and  includes  the 
inspiration  of  oxygen,  hydrogen,  and  other  gases.  Fouicroy  (in  the 
Annales  de  Chimie,  No.  4.  Paris  1790),  gives  the  result  of  the  inspi- 
ration of  oxygen  in  twenty  cases  ;  in  all  it  was  prejudicial,  hastening 
the  progress  of  the  disease,  and  increasing  the  febrile  symptoms. 
Beddoes  tried  the  effect  upon  himself;  it  occasioned  true  hectic, 
emaciation,  dry  cough  and  dyspnœa.     Increased  excitement  is  also 


TREATMENT    OF    PHTHISIS.  515 

the  effect  on  animals,  and  neither  theoretically  nor  practically  is  there 
any  inducement  to  renew  our  experiments. 

The  use  of  hydrogen,  carburetted  hydrogen  and  carbonic  acid,  has 
been  attended  with  much  greater  success.  Beddoes  relates  some 
cases  which  were  greatly  relieved  by  breathing  a  mixture  of  hydrogen 
and  common  air.  In  another  instance,  mentioned  by  Dr.  Crowther, 
the  employment  of  the  carburetted  hydrogen  in  the  proportion  of 
1  part  to  24  of  air,  was  also  useful.  Dr.  Percival,  in  his  Essays, 
1774,  found  the  inspiration  of  carbonic  acid  in  thirty  cases,  palliate 
the  febrile  symptoms.  This  result  is  confirmed  by  the  investigations 
of  Drs.  Withering  and  Hulme.  Dr.  Home,  of  Edinburgh,  says  that 
carbonic  acid  is  useful  in  allaying  fever,  and  an  impure  atmosphere 
is  recommended  by  Darwin  against  hectic.  It  is  also  probable  that 
the  favorable  effects  Avhich  appear  sometimes  to  have  resulted  from  a 
residence  in  cow-houses,  may  in  part  be  ascribed  to  the  same  cause. 
Connecting  with  these  details  the  fact  that  miners  seem  little  liable 
to  phthisis,  and  recollecting  the  opinion  of  Dr.  Wells  and  others,  in 
favor  of  marshy  places  in  consumptive  cases,  there  is  sufficient  evi- 
dence to  justify  some  confidence  in  the  palliative  efficacy  of  these 
gases.  The  subject  is  deserving  of  attention,  and  will  be  viewed 
with  additional  interest,  when  we  reflect  on  those  symptoms  which 
indicate  an  active  state  of  the  respiratory  functions  in  phthisis,  viz., 
increased  heat,  florid  color  of  the  skin  and  mucous  membranes,  and 
compare  them  with  the  physical  condition  of  the  lungs.  The  ab- 
sence of  constant  dyspnoea  and  the  complete  oxygenation  of  the 
blood  are  remarkable  physiological  facts  in  many  examples  of  this 
affection.  Is  it  depending  on  the  circulation  of  oxygen  in  the  venous 
as  well  as  the  arterial  blood,  on  account  of  the  diminished  production 
of  carbonic  acid,  arising  ft-om  impeded  nutrition.' 

Treatment  of  the  more  prominent  Symptoms  of  Phthisis. 

Under  this  division  we  shall  include  hœmoptysis,  hectic  perspira- 
tions, cough  and  diarrhoea. 

Hœmoplysis.  —  The  diagnostic  value  and  importance  of  this  symp- 
tom have  already  been  fully  insisted  upon.  We  can  scarcely  be  said 
to  possess  any  curative  means  against  lisemoptysis  ;  they  arc  ratiier 
preservative  and  palliative.     No  precise  rules  for  their  administration 


516  translator's  appendix. 

can  be  laid  down  ;  the  constitution  of  the  patient,  the  stage  of  the 
disease,  and  the  more  immediate  cause  of  the  hsemoi'rhage,  when 
such  can  be  traced,  require  numerous  modifications  in  the  treatment. 
We  must  also  recollect  that  it  is  very  seldom  fatal  in  its  immediate 
effects,  and  would  in  general  cease,  independently  of  treatment;  we 
must  therefore  be  backward  in  attributing  too  much  efficacy  to  par- 
ticular remedies.  The  means  most  generally  prescribed  under  these 
circumstances,  consist  in  i-est  in  the  horizontal  posture,  cool  air,  cold 
applications  to  the  chest  and  scrotum,  or  between  the  shoulders, 
with  warmth  to  the  extremities,  bleeding,  nauseants,  purgatives, 
sedatives  and  astringents.  It  is  important  to  remember  that  we 
are  treating  a  symptom  only,  and  not  a  disease  ;  this  must  regu- 
late the  activity  of  our  measures,  and  prevent  our  indiscriminately 
resorting  to  powerful  antiphlogistics  ;  though  from  the  experience  of 
Dr.  Cheyne  and  others,  there  is  every  reason  to  suppose,  that  when 
symptoms  of  pulmonary  congestion  and  increased  circulation  are 
present,  small  and  repeated  bleedings  are  among  our  most  effectual 
remedies.  In  the  majority  of  cases,  rest,  with  cool  air,  sponging  the 
chest  with  vinegar  and  water,  the  application  of  warmth  to  the  ex- 
tremities and  saline  laxatives,  will  be  sufficient.  When  the  symp- 
toms persist,  nauseants,  with  sedatives,  such  as  digitalis  and  Prussic 
acid  may  be  tried.  The  former  especially  have  been  highly  spoken 
of  by  Aasheim,  Piso,  Baglivi,  Murray,  and  more  recently  by  Dr. 
Graves  of  Dublin,  who  also  corroborates  the  opinion  of  the  preceding 
authors  on  the  utility  of  small  doses  of  ipecacuanha  in  this  and  other 
hsemorrhages.  Dr.  Graves  prescribes  two  grains  every  quarter  of 
an  hour  until  some  improvement  is  observed,  and  afterwards  every 
half  hour  until  the  flow  of  blood  ceases.  He  precedes  the  ipecacu- 
anha by  a  purgative  injection  and  a  saline  purge.  This  treatment 
he  has  almost  invariably  found  successful.  Dr.  Cheyne  thinks  that 
in  all  cases  where  inflammatory  symptoms  are  present,  a  com- 
bination of  antimony  and  nitre,  frequently  repeated,  is  one  of  the 
most  efficient  remedies.  Emetics  have  been  strongly  advised  by 
Robinson,  Marryat,  Reid,  Stoll,  Dr.  Parr  and  others,  and  from  state- 
ments of  these  writers,  there  can  be  no  doubt  that  the  danger  to 
be  apprehended  from  their  use  has  been  greatly  exaggerated.  The 
action  of  vomiting  on  the  pulmonary  circulation  is  not  so  easily  de- 


TREATMENT    OF    PHTHISIS.  517 

termined.  The  venous  congestion  of  the  head  and  upper  extremi- 
ties, and  the  probable  repetition  of  this  state  in  the  lower,  from  the 
contraction  of  the  abdominal  parietes,  combined  with  the  diminished 
action  of  the  heart  and  the  subsequent  rapid  diaphoresis,  lead  us  to 
conclude  that  it  is  not  attended  with  danger  in  hsemorrhage  of  the 
lungs.  The  effects  of  sea  sickness  and  the  relief  which  vomiting 
affords  to  dyspnœa,  arising  from  a  congested  state  of  the  heart  and 
lungs,  are  not  compatible  with  the  idea  of  any  increase  of  blood  in 
those  organs.  Perhaps  since  the  principal  advantages  of  nauseants 
and  emetics  arise  from  their  action  on  the  heart,  and  their  tendency 
to  equalize  the  circulation,  the  former  should  generally  be  pre- 
ferred. 

A  tea-spoonful  of  common  salt,  swallowed  dry  or  dissolved  in 
water,  has  been  successful  in  the  hands  of  Le  Meza,  Rush  and 
others,  and  from  its  being  easily  procured,  is  worth  remembering. 
Dr.  Carmichael  Smyth  speaks  highly  of  the  efficacy  of  the  extract  of 
hyoscyamus.  Opium  is  not  admissible  until  after  depletion.  Sul- 
phuric acid,  vinegar,  acetate  of  lead,  ratanhia  and  other  astringents, 
may  be  occasionally  useful.  Cold  water  and  small  pieces  of  ice  taken 
internally  are  valuable  adjuncts  in  acute  and  incipient  cases.  Liga- 
tures to  the  limbs  are  too  painful  to  be  applied,  unless  the  quantity 
of  blood  renders  the  danger  imminent.  Dry  cupping  has  been  re- 
cently recommended,  particularly  where  depletory  measures  are  con- 
tra-indicated, and  in  the  more  advanced  stages  in  these  and  other 
circumstances  it  may  be  advantageously  employed.  In  the  treatment 
of  hajmoptysis  the  state  of  the  liver  and  bowels  should  be  particularly 
attended  to. 

Hectic  Fever.  —  This  is  evidently  not  confined  to  the  latter  stage 
of  the  disease,  neither  does  it  depend,  as  M.  Broussais  has  argued, 
on  the  absorption  of  pus  from  tubercular  abscesses,  nor  does  it  always 
correspond  to  the  extent  of  pulmonary  disorganization.  The  fact, 
that  secondary  alterations  are  proportionate  in  number  and  impor- 
tance to  the  violence  and  duration  of  febrile  movement,  points  out 
the  necessity  of  diminishing,  as  much  as  possible,  vascular  excite- 
ment ;  never  forgetting  the  natural  tendency  of  the  disease,  and 
avoiding  the  use  of  means  calculated  to  hasten  the  development  of 


518  translator's  appendix. 

those  secondary  symptoms,  which  so  powerfully  influence  the  pro- 
gress and  accelerate  the  termination  of  phthisis. 

In  the  treatment  of  hectic  we  should  rather  confide  in  attention  to 
general  measures,  such  as  diet,  clothing,  early  rising,  ventilation, 
tepid  sponging,  warm  bath,  &c.,  than  in  the  administration  of  medi- 
cine. Tn  acute  and  incipient  cases  more  active  means  may  occasion- 
ally be  advisable,  and  here  it  is  that  small  bleedings  have  been  prin- 
cipally of  service.  Small  doses  of  tartarized  antimony  and  saline  med- 
icines may  be  successfully  employed  under  the  same  circumstances. 

Since  hectic  fever  has  been  regarded  as  an  attendant  upon  rather 
than  essential  to  the  disease,  specific  remedies  have  diminished  both 
in  number  and  value,  and  against]a  symptom  associated  with  such  a 
variable  state  of  the  general  health,  means  of  the  most  opposite  de- 
scription may  be  occasionally  successful.  Poterius  was  in  the  habit 
of  prescribing  a  preparation  which  was  long  regarded  as  a  valuable 
anti-hectic.  It  consisted  of  one  part  of  tin,  one  of  metallic  antimony, 
deflagrated  with  six  of  nitre.  Other  Avriters  seem  to  have  found  it 
useful.  Reid  advises  a  powder  containing  fifteen  grains  of  nitre  and 
one  of  tartar  emetic.  Sydenham  speaks  highly  of  an  infusion  of  two 
drachms  of  rhubarb  in  a  quart  of  mild  beer  or  other  liquid  for  chil- 
dren, when  the  febrile  symptoms  are  not  intense.  Vinegar  and  water 
was  much  praised  by  Galen  as  the  best  refrigerant,  and  if  we  recol- 
lect its  astringent  properties,  perhaps  its  employment  in  phthisis  has 
been  too  much  neglected.  M.  Orban  (Vide  Thompson's  Mat.  Med., 
p.  35),  both  at  Tunis  and  in  France,  used  it  extensively  in  consumption, 
and  says  that  its  effects  were  always  beneficial  when  it  produced 
a  costive  state  of  the  bowels.  The  quantity  taken  daily  was  seven 
ounces  diluted  with  forty-nine  ounces  of  rain  water.  Small  doses  of 
alum  and  sulphate  of  iron  were  prescribed  at  the  same  time.  Dr. 
Roberts  (Medical  Transactions  of  the  Coll.  Phys.,  vol.  v.)  strongly 
advocates  the  use  of  vinegar  for  checking  the  hectic  and  morning 
sweats,  restraining  hasmoptysis,  and  producing  costiveness.  Dr. 
Thompson  speaks  favorably  of  its  palliative  influence,  and  occasion^ 
ally  prescribed  it  with  the  infusion  of  columba  or  carscarilla.  Its  ex- 
ternal use  has  already  been  mentioned,  and  we  think  its  internal 
deserving  of  further  trial.  Different  combinations  of  the  sedatives 
and  narcotics  are  often  available.    It  is  in  those  cases  where  the 


TERATMENT    OF    PHTHISIS.  519 

hectic  symptoms  are  urgent,  that  the  pneumatic  method  promises  to 
be  of  service. 

Perspirations.  —  These  are  usually  classed  among  the  symptoms 
of  hectic,  though  in  phthisis  they  are  doubtless  in  part  supplementary 
to  the  pulmonary  functions.  The  general  means  enumerated  in  the 
preceding  section  must  form  the  basis  of  our  treatment.  When 
these  are  not  successful,  the  use  of  sulphur  deserves  attention,  and 
in  cases  where  the  sweating  is  partial,  nitre  and  opium,  as  recom- 
mended by  Bennett  and  Hoffman,  may  be  tried.  When  febrile  symp- 
toms are  present,  sudorifics  may  be  successfully  employed  in  check- 
ing perspirations.  Adair  and  others  have  advocated  the  use  of 
emetics  on  the  same  grounds,  Morton  advises  waking  the  patient 
just  before  the  perspirations  come  on,  Percival  recommends  the 
external  application  of  the  decoction  of  bark  ;  this  is  also  mentioned 
by  Broussais,  The  sulphuric  acid  is  one  of  the  most  effectual  means  ; 
the  vegetable  acids  and  the  acetate  of  lead  internally  or  in  lotions 
may  also  be  tried.  Our  object  is  rather  to  moderate  than  altogether 
to  prevent  perspirations,  which  may  be  considered,  when  not  extreme, 
as  beneficial.  Exact  ideas  of  how  far  the  skin  may  be  supplementary 
to  the  lungs  are  still  wanting. 

Diarrhœa.  — This  can  be  no  longer  regarded  as  a  simple  attendant 
upon  the  hectic  fever,  but  in  the  great  majority  of  instances  is  de- 
pending on  local  inflammation,  which  is  sooner  or  later  followed  by 
ulceration.  The  knowledge  of  this  fact  will  at  once  regulate  the 
treatment  of  diarrhœa  in  phthisis,  more  particularly  in  the  early  stages 
of  the  disease,  and  demonstrates  the  injurious  tendency  of  the  pur- 
ging system  too  frequently  resorted  to,  as  well  as  the  necessity  of 
avoiding  the  use  of  either  medicine  or  food  which  unnecessarily 
stimulates  the  digestive  mucous  membrane.  We  have  seen  how 
rapidly  the  disease  progresses  when  abdominal  symptoms  are  con- 
joined with  the  thoracic  ;  the  state  of  the  alimentary  canal,  and  its 
liability  to  inflammation,  should,  therefore,  we  repeat,  be  constantly 
kept  in  view  in  the  treatment  of  phthisis.  Our  best  preserva- 
tive and  curative  measures  consist  in  warm  clothing  ;  mild  tempera- 
ture ;  great  attention  to  the  skin  ;  bland  nutritious  diet  ;  the  use  of 
only  mild  purgatives  when  necessary  ;  or  what  is  still  preferable, 
eiiemata  ;  also  the  hip  bath,   and  local  blood-letting  when  symptoms 


520  translator's  appendix. 

of  inflammation  are  present.  To  these  means  we  may  add  mucila- 
ginous drinks  small  doses  of  rhubarb,  hydrargyrum  cum  cretà,  ipe- 
cacuanha, Dover's  powder,  chalk  mixture,  white  decoction,  and 
other  slightly  astringent  drinks,  as  lime  water  and  milk,  or  infusion 
of  pomegranate  and  milk. 

In  severe  and  more  advanced  cases  Dr.  Stokes  speaks  highly  of  the 
effect  of  a  large  blister  on  the  abdomen.  Dr.  Graves  thinks  a  grain  of 
the  nitrate  of  silver,  given  three  or  four  times  a  day,  is  one  of  the  best 
remedies.  When  arresting  the  discharge  is  important,  the  turpen- 
tines and  balsams,  given  as  enemata,  with  opium  may  be  resorted 
to.  The  sulphate  of  copper  and  acetate  of  lead,  with  opium,  have 
been  occasionally  successful.  Strychnia,  a  combination  of  cusparia, 
nitric  acid  and  laudanum,  and  with  discximation,  diffusible  stimulants, 
have  proved  advantageous  in  particular  circumstances.  It  is  only  by 
a  knowledge  of  the  pathology  of  diarrhœa  in  phthisis,  that  our  reme- 
dies can  be  rationally  or  successfully  applied. 

Cough.  —  Tranquillizing  the  cough  is  an  important  indication.  By 
interrupting  sleep  and  accelerating  the  circulation,  it  exerts  a  power- 
ful influence  over  the  general  comfort  and  health  of  the  patient. 
Before  tubercular  softening  has  taken  place,  and  communication 
established  with  the  bronchia,  the  expectoration  remaining  white  and 
frothy,  coughing  cannot  be  regarded  as  a  salutary  effort,  but  the 
result  of  pulmonary  irritation,  and  should  be  treated  accordingly.  At 
a  later  period  it  is  evidently  necessary  to  avoid  suffocation,  but  even 
then  its  frequency  and  violence  may  be  advantageously  moderated. 
In  addition  to  those  general  measures  to  which  we  have  so  often  re- 
ferred, the  cough  may  be  calmed  by  mucilaginous  mixtures,  decoction 
of  Iceland  moss,  small  doses  of  hyoscyamus,  Prussic  acid,  digitalis, 
the  different  preparations  of  opium,  aether,  the  inhalation  of  emollient 
and  narcotic  vapors,  breathing  the  gases  advised  in  the  pneumatic 
method,  and  occasionally  by  the  use  of  small  doses  of  tonics,  or  the 
employment  of  antiphlogistics,  as  the  general  state  of  the  patient  may 
indicate.  In  the  more  advanced  stages,  when  bronchitis  and  ulcera- 
tion are  present,  we  must  be  guided  in  our  treatment  by  the  intensity 
of  the  febrile  symptoms.  It  is  at  this  period  that  the  trial  of  chlorine 
and  iodine  inhalations  have  been  particularly  recommended,  though 
in  many  cases  their  use  during  the  first  stage  of  the  disease  ought 


TREATMENT    OF    PHTHISIS.  521 

not  to  be  neglected.  The  activity  of  these  agents  may  be  moderated 
by  combining  them  with  different  narcotics.  Sulphur,  turpentine, 
copaiba,  are  often  serviceable  in  chronic  cases.  Emetics  and  nau- 
seants  are  valuable,  but  as  well  as  expectorants  in  general,  must  not 
be  prescribed  without  attention  to  the  state  of  the  gastric  mucous 
membrane.  Sinapisms  to  the  chest  with  pediluvia  often  relieve 
urgent  symptoms,  and  Avhen  suffocation  is  threatened  from  bronchial 
obstruction,  these  means  with  emetics  and  diffusible  stimuli  are  our 
principal  resources. 

There  are  many  other  incidental  indications  which  we  have  pur- 
posely omitted.  Our  object  in  this  rapid  sketch  was  to  present  to 
the  mind  of  the  younger  portion  of  our  readers,  an  outline  of  the 
more  prominent  pathological  features  of  consumption  ;  to  expose 
some  of  those  general  principles  of  treatment  which  may  fairly  be 
deduced  from  our  present  knowledge  of  its  causes  and  morbid  altera- 
tions, and  to  direct  his  attention  to  those  remedial  measures  which 
have  been  advised  either  for  its  palliation  or  cure,  by  numerous  and 
judicious  practitioners  ;  not  attempting  to  define  their  modus  operandi, 
or  subjecting  them  to  the  ordeal  of  any  pathological  theory.  In  the 
course  of  our  inquiries  we  have  often  been  discouraged  by  the  abun- 
dance and  contradictory  nature  of  the  materials  presented  to  our 
notice  ;  while,  at  the  same  time  we  have  felt  surprised  at  the  ease 
with  which  closet  therapeutics  may  be  invented,  and  those  ad  libi- 
tum pathological  combinations  conjured  up,  for  the  removal  of  which 
our  remedies  are  so  conveniently  and  accurately  adjusted.  It  would 
not  have  been  difficult  to  have  minutely  detailed  a  multitude  of  pre- 
cise and  definite  regulations  for  the  treatment  of  phthisis,  and  per- 
haps to  have  impressed  the  minds  of  some  with  a  favorable  idea  of 
our  superior  curative  acumen  ;  but  we  have  studiously  endeavored  to 
avoid  the  inducements  which  empiiical  reputation  in  medicine  holds 
out,  convinced  that  there  are  few  obstacles  more  fatal  to  the  progress 
of  science  and  improvement,  than  those  preposterous  pretensions 
which  quackery  so  uublushingly  propagates,  at  the  expense  of  all 
honorable  feeling  and  to  the  detriment  of  the  health  of  a  too  easily 
deluded  population. 

Notwithstanding  all  that  has  been  written  and  done  upon  the  sub- 
s  3 


522  translator's  appendix. 

ject  of  consumption,  we  are  still  totally  unacquainted  with  anything 
like  a  satisfactory  method  of  cure,  and  it  is  only  Avhen  the  upright 
spirit  of  inquiry  which  has  characterized  our  author's  researches, 
shall  have  equally  pervaded  the  minds  of  those  who  are  continuing 
the  investigation,  that  any  decided  increase  to  our  present  knowledge, 
or  rather  the  removal  of  our  present  ignorance,  may  be  expected. 
To  be  strictly  honest  in  medicine  requires  unusual  probity  and  devo- 
tion ;  our  efforts  must  not  be  undertaken  with  the  eager  hope  of  dis- 
covery, but  with  the  conviction  that  at  best  we  can  only  furnish  our 
item  to  the  now  accumulating  mass  of  accurate  observation,  from 
which  medicine  as  a  science  shall  hereafter  be  eliminated.  In  looking 
back  on  what  has  yet  been  accomplished,  and  comparing  it  with 
what  remains  to  be  done,  we  can  ot  avoid  the  impression  that  we 
are  now  executing  the  labor  by  which  future  generations  are  to  pro- 
fit; but  with  the  present  means  of  observation  in  our  power,  and  the 
facilities  for  recording  and  communicating  the  results  of  our  inquiries 
what  may  we  not  anticipate  from  the  united  exertions  of  minds  alive 
to  the  advantages  to  be  gained  by  systematic  research,  and  called 
into  action  "  under  circumstances  different  from  any  which  have  yet 
existed  in  the  world,  and  over  an  extent  of  territory  far  surpassing 
that  which  has  hitherto  produced  the  whole  harvest  of  human  in- 
tellect." 


AMERICAN    EDITOR'S    APPENDIX 


Section    I.  —  Prescriptions. 

For  various  prescriptions  the  reader  is  referred  to  sections  1  of 
Vols.  I,  and  II,  of  the  Translation  of  Louis  on  Fever. 
The  following  are  not  mentioned  in  the  work  alluded  to. 

1.  Looch,  page  226,  line  27.  There  are  several  preparations  un- 
der the  general  name  of  Looch.  They  are  composed  of  several 
articles  mixed  with  sugar  and  syrups.  The  Looch  Blanc,  which  is 
probably  referred  to  in  the  present  work,  is  made  as  follows,  — 

R  Sweet  Almonds  No.  xij. 

Bitter        do.  "     ij. 

Water  §  iv. 

White  Sugar  §  i. 

Gum  Tragacanth  grs.  xv. 

Orange  Flower  Water  5  U- 
Mix  in  a  mortar  after  having  made  a  paste  of  the  almonds  by  rub- 
bing them  with  sugar  and  water.  —  Fot. 

2.  Pectoral  Mixture,  page  265,  line  7.  I  find  in  the  Formulary  of 
Edwards  and  Vavasseur  two  pectoral  potions,  but  whether  either  of 
them  is  the  one  referred  to  by  Louis,  it  is  imposible  for  me  to  decide. 
The  active  principle  of  both  is  the  Hydrocyanic  Acid. 


524  AMERICAN    editor's     APPENDIX. 

3.  Pectoral  Ptisan,  page  265,  line  7. 

R  Malv.  Flor. 

Althœse  " 

Tussilag.  " 

Papav.  Rh.       "     ââ  part,  equal.  M. 
Take  3i.  or  3ij.  of  this  mixture  and  infuse  for  twenty  minutes  in 
boiling  water  Ibij.      Then    strain   and  add    Marsh   Mallow   Syrup 
ibs.ij.  —  FoT  AND  Ntsten's  Dictionary. 

4.  Syrup  of  Five  Roots,  page  30,  line  5. 

K:  Rad.  Asparagi  Off. 

Rad.  Rusci  Aculeat.  ââ   §  v. 
Aq.  fcvii. 

Boil  to  one  half. 

R;  Apii  graveolent. 
Aneth.  Fœniculi. 
Apii  Petroselin.  ââ  §  v. 

Aq.  calid  .  Ibij- 

Infuse  and  mix  the  two  liquids  and  add  Ibvi.  of  sugar.    To  be  used 
in  potions  of  Sij- to  §j.  to  sweeten  drinks.  —  Edwards  and  Vav- 

ASS£UR. 


Section    II.  —  Peculiar    Terms. 

Mamelonné.  This  word  was  translated  mamelonated  in  the  work 
on  Fever,  but  throughout  this  one  the  term  mammillated  has  been 
retained.  It  is  a  correct  English  word,  and,  therefore,  is  more  prop- 
erly used  than  the  word  I  introduced.  The  only  objection  to  it  in 
my  own  mind  is,  that  it  seems  to  convey  something  more  than  the 
French  expression  does. 

Crèmes  de  riz.  These  words  in  the  other  work  are  translated 
rice  fritters.  Dr.  Cowan's  Translation  is  undoubtedly  the  better  one 
of  the  two.    He  uses  the  term  rice-creams. 

Pelotonnée.  This  word  it  is  very  important  that  the  reader  should 
understand  correctly.    I  have  used  the  word  nummulated,  not  be- 


PECULIAR    TERMS.  525 

cause  I  conceive  it  to  be  the  best,  but  because  Dr.  Cowan  used  it 
at  first.  I  say  at  first,  for  Dr,  Cowan  has  not  thought  it  necessary  to 
translate  it  always  so.  In  this  edition  the  word  nummulated  is  always 
used,  whereby  I  mean  to  express  that  condition  of  the  expectoration 
in  which  the  sputa  are  greenish,  flat,  distinct,  sometimes  ragged, 
and  are  floating  in  a  thin  fluid. 

Verge tures.  Dr.  Cowan  translates  by  the  word  vibices.  This  is 
diflFerent  from  the  expression  made  use  of  in  the  work  on  Fever. 
Perhaps  it  is  better.    Vide  Louis  on  Fever,  Vol.  I,  page  339. 


REPORT 


[In  the  edition  which  I  have  of  the  work  (Paris,  1825),  the  following 
Report  is  introduced  by  the  publishers,  from  the  hope  that  it  would  be  inter- 
esting to  the  reader  ;  for  the  same  reason  I  introduce  it  here,  though  Dr. 
Cowan  omits  it.] 


Report  made  to  the  Royal  Academy  of  Medicine  upon  a  Manuscript 
entitled,  —  Anatomico -Pathological  Researches  upon  Phthisis. 
By  M.  Louis. 

You  have  commissioned  MM.  Bourdois,  Royer-Collard  and  myself 
to  present  a  Report  to  you  upon  a  Manuscript  by  M.  Louis,  entitled 
Anatomico-Pathological  Researches  upon  Phthisis.  This  subject 
has  been  so  thoroughly  treated  by  Bayle,  that  any  succeeding  writer 
upon  it  must  almost  unavoidably  be  exposed  to  an  unfavorable  preju- 
dice ;  but  this  prejudice  is  soon  overcome,  when  we  are  acquainted 
with  the  circumstances  which  induced  M.  Louis  to  write  upon  this 
subject,  and  with  the  results  to  which  his  observations  have  led  him. 

At  an  age  when  physicians  in  general  cease  their  attendance  at 
hospitals,  and  forego  the  collecting  of  cases  in  order  to  devote 
themselves  exclusively  to  practice,  M.  Louis  quitted  practice  to  de- 
vote himself  entirely  to  the  study  of  facts.  He  has  collected,  from 
the  month  of  October,  1821  to  the  present  time,  Avith  extreme  care 
the  history  of  all  the  patients  who  have  been  admitted  into  the  wards 
St.  John  and  St,  Joseph  of  the  hospital  of  La  Charité.  The  number 
of  these  patients  is  1960,  of  whom  358  died.  Of  the  last,  123  died 
from  phthisis,  and  40  others,  who  were  carried  off  by  different  dis- 


528  academy's  report. 

eases,  had  tubercles  in  the  lungs.  This  lesion,  then,  existed  in 
nearly  a  half  of  those  who  died,  and  was  in  the  third  of  them  the 
principal,  if  not  the  only,  cause  of  death.  The  comparison  of  so 
great  a  number  of  facts,  which  he  had  at  first  collected  for  his  own 
instruction  only,  has  presented  M.  Louis  with  results  of  such  impor- 
tance, that  he  has  thought  it  to  be  his  duty  to  offer  them  to  the 
Academy. 

This  work  is  divided  into  two  parts  ;  the  first  is  devoted  to  the 
examination  of  the  anatomical  lesions,  observed  in  the  lungs  and 
in  other  organs  ;  the  second,  to  the  exposition  of  the  symptoms  which 
are  connected  with  each  of  these  lesions.  The  author  has  added 
some  considerations  with  regard  to  the  general  history  of  phthisis,  its 
causes  and  duration  ;  and  from  the  observations  which  he  has  col- 
lected, and  which  form  the  basis  of  his  work,  he  has  selected  fifty, 
which  he  has  reported  in  confirmation  of  the  results  which  he  pre- 
sents. 

It  is  only  of  tubercular  phthisis  that  he  treats  ;  he  thinks,  with  M. 
Laennec,  that  the  granulations  of  Bayle  are  only  commencing  tuber- 
cles, and  that  cancer,  ulceration,  melanosis  and  calculi  of  the  lungs 
ought  to  be  referred  to  other  orders  of  diseases. 

First  Part.  — The  anatomical  lesions  observed  in  the  lungs  have 
been  so  well  described  by  Bayle  and  Laennec,  that  the  author  has 
limited  himself  to  a  very  concise  description,  in  which,  however,  we 
find  many  remarks  peculiar  to  himself.  He  has  observed,  for  ex- 
ample, that  tubercles  not  only  particularly  affect  the  apex  of  the 
lungs,  as  has  been  said,  but  also,  when  they  invade  their  different 
lobes,  that  those  of  the  apex  are  more  numerous  and  larger,  and  that 
they  become  soft  at  a  period  when  those  of  the  base  are  still  hard. 
He  thus  establishes  the  fact,  that  the  differences  with  regard  to  the 
number,  size,  and  the  more  or  less  advanced  state  of  the  tubercles 
apply  more  exactly  to  the  superior  lobe  compared  with  the  inferior, 
than  to  the  apex  compared  with  the  base.  He  has  often  found  the 
superior  lobe  entirely  disorganised,  and,  at  the  same  height  the  cor- 
responding parts  of  the  superior  lobe  still  permeable  to  the  air  and 
containing  a  few  tubercles  only.  These  remarks  are  followed  by  two 
very  curious  cases,  one  in  wliicli  a  large  excavation  was  filled  b}?^  a 
fibrinous  clot,  and  another  in  which  a  fragment  of  the  pulmonary 


academy's  report.  529 

substance,  perfectly  sound  to  appearance,  was  inclosed  in  a  cavity 
without  adhering  on  any  side  to  its  parietes. 

The  air  passages  have  presented  M.  Louis  with  lesions,  which 
have  been  but  imperfectly  described  by  Bayle.  This  physician 
found  a  lesion  of  the  larynx  in  17  cases  only  of  100  ;  ulcer- 
ations of  the  trachea  are  still  more  rare  according  to  him,  and 
he  does  not  even  make  known  the  proportion  of  cases  in  which  he 
met  with  them  ;  he  says  nothing  of  those  of  the  epiglottis.  Of  102 
patients,  M.  Louis  found  the  epiglottis  ulcerated  in  18,  the  larynx 
in  23,  and  the  trachea  in  31.  In  many  cases  he  has  seen  the 
ulcerations  of  the  trachea  occupying  the  whole  muscular  portion, 
and  in  one  case  many  of  the  cartilaginous  rings  completely  destroyed 
in  a  part  of  their  extent  by  the  progress  of  the  ulcer.  As  to  the 
mucous  membrane  of  the  bronchia,  it  did  not  frequently  present  any 
alteration  in  the  neighborhood  of  crude  tubercles,  whilst  it  was  al- 
most always  thickened  and  of  a  red  color  in  the  neighborhood  of 
cavities,  and  especially  of  those  which  were  very  large,  and  which 
we  naturally  consider  of  long  standing.  From  this  circumstance 
he  concludes  that  inflammation  of  the  mucous  membrane  of  the 
bronchia  being  posterior  to  the  softening  of  the  tubercles,  cannot  be 
considered  as  their  cause,  but  much  rather  the  effect  of  the  irritation 
from  the  matter  poured  into  the  bronchia  from  the  cavities.  The 
situation  of  the  ulcerations  of  the  trachea,  which  are  more  numerous 
and  larger  at  its  back  part,  and  that  of  the  ulcerations  of  the  epi- 
glottis, which  almost  exclusively  occupy  the  laryngeal  surface,  in- 
duce us  to  believe,  according  to  M.  Louis,  that  the  irritation  of  these 
parts  by  the  contact  of  the  sputa,  is  one  of  the  causes  which  produce 
them. 

In  a  tenth  of  the  patients  the  pulmonary  parenchyma  was  the  seat 
of  an  acute  inflammation,  which  supervened  a  short  time  before  death. 

The  adhesions  of  the  pleura,  which  are  so  common  in  patients  with 
phthisis,  have  especially  engaged  the  attention  of  the  author.  He 
has  found  the  lungs  perfectly  free  from  them  in  one  case  only.  He 
has  generally  observed  a  kind  of  proportion  between  the  adhesions 
and  the  internal  disorder;  when  the  adhesions  were  weak  and  of 
small  extent,  the  examination  of  the  lungs  presented  very  small  cavi- 
t3 


530  academy's  report. 

ties  ;  but  when  these  adhesions  were  strong  and  of  great  extent,  the 
eavities  were  ahiiost  always  very  large. 

It  has  been  for  a  long  time  observed  that  tubercles  are  often  de- 
veloped in  many  organs  at  the  same  time,  and  that  in  the  phthisical 
especially,  we  frequently  meet  with  them  in  other  parts  at  the  same 
time  that  we  find  them  in  the  lungs.  Bayle  proved  the  presence  of 
tubercular  matter  in  the  intestines  ;  but  no  one  has  hitherto  pre- 
sented the  numerical  results  contained  in  the  work  of  M.  Louis.  He 
has  recognised  the  presence  of  tubercles  or  of  tuberculous  matter» 

in  the  small  intestine,  in  nearly  a  third  of  the  patients  ; 

in  the  large  intestine,  in  a  ninth  ; 

in  the  mesenteric  glands,  in  a  fourth  ; 

in  the  cervical  glands,  in  a  tenth  ; 

in  the  lumbar  glands,  in  a  twelfth  j 

in  the  prostate,  in  a  thirteenth  ; 

in  the  spleen,  in  a  fourteenth  ; 

in  the  ovaries,  in  a  twentieth  ; 

in  the  kidneys,  in  a  fortieth  ; 

in  the  uterus, 

in  the  brain, 

in  the  cerebellum,  )in  one  patient  only. 

in  the  medulla  oblongata, 

in  the  ureters, 

These  researches,  made  with  the  greatest  care,  have  led  M. 
Louis  to  a  very  important  result.  Not  one  of  the  358  subjects, 
whom  he  examined  after  death,  presented  tubercles  in  any  organ, 
who  did  not  also  have  thorn  in  the  lungs.  The  tuberculous  con- 
cretions, which  are  formed  in  the  chronic  inflammations  of  serous 
membranes,  are  not  even  an  exception.  In  all  the  cases  of  this  de- 
scription which  presented  themselves  to  M.  Louis,  the  attentive  ex- 
amination of  the  lungs  has  led  him  to  the  discovery  of  tubercles  in 
these  organs.  In  a  single  individual,  who  died  from  a  severe  fever, 
and  whose  lungs  appeared  sound,  the  mesenteric  glands  contained 
some  tuberculous  grains.  Will  this  observation,  which  has  been 
made  with  regard  to  350  patients  over  fifteen  years  of  age,  apply  to 
infants  ?  This  question  can  be  answered  only  by  numeroua  post- 
mortem examinations. 


academy's  report.  531 

The  anatomical  study  of  organs,  which  are  not  the  special  seat  of 
phthisis,  has  supplied  M.  Louis  with  many  other  interesting  facts. 

The  heart  was  not  increased  in  size  except  in  three  cases,  and  this 
increase  occurred  in  the  left  ventricle.  In  the  few  cases  in  which 
an  alteration  in  the  thickness  of  the  heart  presented  itself,  it  was 
almost  always  on  the  left  side.  These  facts  point  out  the  true  value 
of  the  theories  of  some  authors,  Avho  consider  the  tuberculous  hard- 
ening of  the  lungs  as  one  of  the  most  active  causes  of  diseases  of  the 
heart  in  general,  and  particularly  of  the  right  cavities.  In  the  major- 
ity of  phthisical  patients,  M.  Louis  found  the  heart  diminished  in  the 
same  proportion  as  the  other  viscera.  The  aorta,  when  measured 
for  comparison,  and  through  its  whole  length,  in  patients  who  died 
from  phthisis  and  from  other  affections,  was  found  more  contracted 
in  those  who  died  from  phthisis  than  in  those  who  died  from  acute 
affections,  but  less  so  than  in  those  who  died  from  cancerous  affec- 
tions. In  a  fourth  of  the  cases,  the  aorta  presented  a  remarkable 
redness  on  its  internal  face,  but  without  any  change  in  the  consistence 
and  thickness  of  its  membranes.  Neither  these  lesions  nor  those  of 
the  pharynx,  oesophagus  and  stomach,  which  follow,  were  observed 
by  Bayie. 

Ulcerations  of  the  œsophagus  and  pharynx  occurred  twice  only. 
The  œsophagus  also  presented  in  three  cases  a  thinning  with  a  soft- 
ening of  its  membranes  at  its  cardiac  extremity.  Ulcerations  of 
the  pharynx  and  oesophagus  were  not  met  with  in  any  individuals 
who  died  from  other  chronic  diseases  ;  they  are  were  observed  only 
in  those  who  have  died  from  phthisis  and  from  typhus  fever. 

In  9  cases  of  96  in  which  the  stomach  was  carefully  examined, 
M.  Louis  found  it  twice  or  three  times  its  usual  size  ;  the  great 
curvature  descended  as  far  as  the  crest  of  the  ilium.  The  same 
change  in  the  size  and  situation  of  the  stomach  was  only  twice  ob- 
served in  patients  who  died  from  other  diseases.  However  remarka- 
ble this  phenomenon  is,  the  structure  of  the  stomach  presents  lesions 
of  much  more  importance,  and  which  have  already  been  pointed  out 
by  the  author  in  his  Memoir  upon  the  softening  and  thinning  of  the 
Mucous  Membrane  of  the  Stomach.  A  careful  examination  of  this 
membrane  in  96  cases  of  phthisis,  offered  in  77  of  them  remarkable 
lesions,  such  as  softening  with  thinning,  redness  with  thickening,  a 


532  academy's  report. 

mamillated  aspect,  &c.  ;  in  two  cases,  it  presented  two  ulcerations 
without  change  in  its  structure  or  color.  A  comparative  examination 
of  the  same  membrane  in  about  the  same  number  of  fatal  cases  of 
other  chronic  diseases  presented  alterations  in  one  half  of  them  only, 
end  these  alterations  were  of  less  extent  ;  the  softening  with  thin- 
nino',  which  was  observed  in  19  cases  out  of  96  of  phthisis,  was  found 
only  six  times  in  94  cases  of  other  chronic  diseases.  Thus,  lesions 
of  the  stomach  are  much  more  frequent  and  severe  in  phthisis  than 
in  other  affections. 

The  duodenum  presented  some  ulcerations  in  three  cases,  and  an 
increased  size  of  its  mucous  crypts  in  a  certain  number  of  instances. 

The  study  of  the  anatomical  lesions,  which  are  frequently  seated 
in  the  small  intestines,  has  fixed  the  attention  of  M.  Louis  upon  the 
elliptical  patches  which  are  formed  by  the  agglomeration  of  the  mu- 
cous crypts,  spoken  of  by  some  anatomists,  though  the  importance 
they  deserve  has  not  generally  been  attached  to  them.  M.  Louis 
has  observed  that  these  patches,  which  exist  in  a  sound  state,  and 
which  are  situated  opposite  the  mesentery,  participate  but  very 
slightly  in  the  lesions  of  the  surrounding  mucous  membrane,  and  are 
often  the  seat  of  lesions  in  which  this  membrane  takes  no  part. 
These  patches  are  the  most  usual  seat  of  ulcerations,  both  in  phthisis 
and  in  severe  fevers.  M.  Louis  has  found  these  ulcerations  in  five 
sixths  of  the  cases  of  phthisis,  which  induces  him  to  believe  that  he 
has  examined  these  organs  with  more  care  than  even  the  scrupulous 
Bayle,  who  did  not  discover  lesions  of  the  intestines  but  in  two  thirds 
of  his  cases.  The  development  of  these  ulcers  also  presented  this 
remarkable  circumstance,  namely,  when  they  were  confined  to  the 
mucous  membrane,  the  cellular  was  very  thick,  and  when  this  was 
destroyed  by  them,  the  muscular  coat  was  equally  thickened  ;  ao 
that  at  the  same  time  that  one  of  the  membranes  was  undergoing 
ulceration,  the  other  was  acquiring  a  greater  thickness,  and  was  thus 
retarding  the  perforation  of  the  intestine.  The  mucous  membrane» 
moreover,  is  sometimes  reddened  ;  it  is  seldom  softened  and  thick- 
ened. 

Ulcerations  were  not  so  frequently  found  in  the  large  intestine  as 
in  the  small,  but  they  were  larger.  M.  Louis  has  many  times  ob- 
served the  caecum  and  ascending  colon  ulcerated  throughout.    The 


academy's  report.  533 

softening  of  the  mucous  membrane  occurred  more  frequently  than  in 
the  small  intestine,  namely,  in  three  fourths  of  the  cases. 

The  tuberculous  degeneration  of  the  lymphatic  glands  of  the  mes- 
entery was  observed,  as  we  have  stated,  in  a  fourth  of  the  cases,  in 
all  of  which  there  were  ulcers  in  the  intestines  ;  but  the  tubercles 
were  far  from  being  in  proportion  to  the  number  and  size  of  the 
ulcers.  In  one  case  in  particular,  in  which  all  the  mesenteric  glands 
were  tuberculous,  there  was  throughout  the  intestinal  tube  only  one 
very  small  ulcer  of  a  line  in  diameter,  occupying  the  small  intestine 
the  mucous  membrane  being  in  other  respects  perfectly  sound 
throughout.  In  many  cases  in  which  the  intestines  were  ulcerated, 
there  was  not  a  single  mesenteric  gland  tuberculous. 

The  author  has  not  found  a  more  constant  relation  between  the 
presence  of  ulcers  in  the  trachea  and  of  tubercles  in  the  cervical 
glands.  He  therefore  concludes  that  the  tuberculous  degeneration 
of  the  lymphatic  glands  ought  to  be  referred  to  some  other  causes 
than  the  inflammation  or  ulceration  of  the  neighboring  membranes. 

The  falty  state  of  the  liver,  observed  by  Bayle,  though  he  did  not 
rigorously  determine  its  frequency,  is  one  of  the  most  remarkable 
lesions  that  occur  in  phthisis  ;  it  seems,  we  may  say,  peculiar  to  this 
affection.  M.  Louis  has  proved  its  existence  in  two  thirds  of  his 
cases  of  phthisis,  whilst  he  has  not  met  with  it  but  twice  in  220  pa- 
tients who  died  from  other  diseases.  He  has  also  ascertained  its 
greater  frequency  in  women  than  in  men,  in  the  proportion  of  nine 
to  two.  The  duodenum  was  sound  in  most  cases.  This  fact  is  of 
no  little  importance  at  present  when  it  is  maintained,  that  diseases  of 
the  glandular  organs  are  always  consecutive  of  those  of  the  neighs 
boring  membranes. 

The  spleen  was  frequently  altered  in  consistence  and  size  in  this 
disease,  as  it  is  in  many  others.  The  tuberculous  degeneration,  as 
we  have  seen,  has  been  many  times  observed  in  it,  as  well  as  in  the 
liver,  the  kidneys,  the  ureters,  the  prostate,  the  vesiculse  séminales, 
the  ovaries  and  the  uterus. 

The  ^cnfonewm  presented  some  traces  of  recent  inflammation  in 
four  cases.  In  another,  there  were  some  semi-transparent  miliary 
granulations.  In  one  case,  the  two  folds  of  this  membrane,  the  epi- 
ploon and  mesentery,  were  formed  of  a  tuberculous  and  of  a  grey, 


534 


ACADEMY  s    REPORT. 


semi-transparent  substance,  imperfectly  mixed  together,  and  had  be- 
come more  than  an  inch  thick. 

The  brain  also  presented  some  remarkable  lesions.  The  lateral  ven- 
tricles contained  from  one  to  three  spoonfuls  of  serous  fluid  in  three 
fourths  of  the  cases,  and  the  sub-arachnoidean  membrane  at  the  upper 
part  of  the  brain  was  infiltrated.  In  five  cases  the  brain  was  softened 
throughout  ;  in  five  others  the  softening  was  partial,  pulpy,  and  limited 
to  the  centre.  The  collection  of  small  granulations,  often  found  at 
the  summit  of  the  brain,  upon  the  sides  of  the  longitudinal  sinus,  and 
considered  by  some  anatomists  to  be  of  a  glandular  nature,  ought  to 
be  regarded,  according  to  M.  Louis,  as  morbid  productions.  He  sup- 
ports this  opinion,  first,  upon  their  entire  absence  in  many  cases  ; 
secondly,  upon  the  inequality  which  they  present  in  their  develop- 
ment, when  they  do  exist,  and  upon  the  alteration  which  is  con- 
stantly found  in  the  arachnoid  in  their  vicinity,  for  it  is  thickened  and 
opaque. 

The  first  part  of  M.  Louis's  work  concludes  with  a  discussion  of 
the  question,  Avhich  of  the  different  lesions  ought  to  be  regarded  as 
peculiar  to  phthisis,  and  which  as  accidental.  He  refers  to  the  first 
class  the  adhesions  of  the  lungs,  or  at  least  those  of  the  apex  in 
many  cases,  the  ulcers  of  the  air  passages  and  of  the  alimentary 
canal,  the  fatty  degeneration  of  the  liver,  and  the  tuberculous  affec- 
tion, wherever  it  may  be  observed  ;  to  the  second  class,  pneumonia, 
acute  pleurisy,  the  softening  of  the  mucous  membrane  of  the  stomach 
and  intestines,  peritonitis,  arachnitis  and  softening  of  the  brain. 

Second  Part.  —  The  author,  after  a  concise  description  of  phthisis, 
always  in  conformity  with  the  facts  which  he  has  collected,  examines 
particularly  some  of  its  principal  symptoms,  and  establishes,  accord- 
ing to  his  observations,  their  frequency,  the  period  of  their  appear- 
ance, and  some  other  circumstances,  which  authors  heretofore  have 
imperfectly  described. 

Hœmoptysis,  with  which  he  commences  this  part,  occurred  in  two 
thirds  of  the  cases  ;  in  a  fifth  it  appeared  before  the  cough  and  ex- 
pectoration. No  one,  who  was  not  affected  with  phthisis,  out  of  i960 
patients  whose  cases  have  been  observed  by  the  author,  had  had 
haemoptysis,  with  the  exception  of  some  individuals  in  whom  it  oc- 
curred in  consequence  of  external  violence,  such  as  a  contusion  of 


academy's  report.  535 

the  chest,  or  a  fall,  and  with  the  exception  of  a  few  females  who  had 
it  in  consequence  of  the  suppression  of  the  catamenia.  The  author, 
therefore,  concludes  that  with  these  exceptions,  a  copious  haemop- 
tysis renders  the  existence  of  tubercles  in  the  lung's  very  probable. 
Your  committee  are  of  opinion  that  this  most  melancholy  conclusion 
is  happily  weakened  by  many  other  facts.  However,  htemoptysis 
is  observed  more  frequently  in  women  than  in  men,  in  the  proportion 
of  three  to  two. 

The  pains  of  the  chest,  experienced  in  phthisis,  may  be  referred 
to  pulmonary  tubercles,  or  to  adhesions  of  the  pleura  ;  and  as  these 
two  lesions  are  almost  always  found  in  conjunction,  it  is  difficult  to 
determine  on  the  examination  of  the  corpse  which  has  produced  the 
pain.  The  acute  sensibility  of  the  pleura,  and  the  well  established 
absence  of  pain  in  a  large  number  of  cases  of  external  or  internal 
tubercles  favor  the  belief,  that  this  pain  is  seated  in  the  external 
membrane  of  the  lungs,  rather  than  in  the  parenchyma.  This,  how- 
ever, is  not  always  the  fact  ;  a  woman,  whose  case  is  reported  in  this 
work,  experienced,  during  the  fifteen  days  immediately  preceding 
her  death,  some  pain  between  the  shoulders,  and  the  examination  of 
the  corpse  presented  only  some  encysted  tubercles  without  any  ad- 
hesions, and,  besides,  all  the  patients,  in  whom  the  adhesions  were 
limited  to  the  apex  of  the  lungs,  did  not  complain  of  pain  in  the  chest. 

The  examination  of  the  _/e&rz7e  attack,  which  comes  on  in  all  cases 
of  phthisis,  at  its  second  period,  presented  the  following  results. 
Chills  occurred  in  five  sixths  of  the  patients  ;  sweats  in  nine  tenths. 
The  opinion  advanced  by  old  authors,  and  repeated  by  all  the  moderns 
that  sweats  alternate  with  diarrhoea,  is  contrary  to  the  facts  observed 
by  M.  Louis,  not  only  in  phthisis,  but  also  in  other  diseases.  The 
author  has  indeed  sometimes  seen  the  diarrhoea  diminished  for  two  or 
three  days  when  the  sweats  appeared,  but  it  soon  resumed  its  former 
intensity,  though  they  lost  none  of  theirs.  In  relation  to  these  copious 
and  prolonged  sweats,  M.  Louis  makes  the  very  natural  remark,  that  a 
function  may  be  for  a  long  time  seriously  altered,  though  the  struc- 
ture of  the  organ,  which  performs  it,  present  no  appreciable  change. 

Diarrhœa  occurred  in  all  the  patients,  with  the  exception  of  1  out 
of  37.  When  it  preceded  death  but  a  short  time,  from  five  to  twenty 
days,  for  example,  we  usually  found  in  the  intestines  but  very  small 


536  academy's  report. 

ulcers,  and  the  mucous  membrane  was  softened,  often  red  and  thick- 
ened. When  the  diarrhœa  was  of  long  standing  and  had  been  con- 
stant, there  were  almost  always  large  and  numerous  ulcers  in  one  or 
the -Other  intestine,  and  sometimes  in  both.  The  diarrhœa  was  no 
less  violent  when  the  ulcers  principally  occupied  the  small  intestine, 
than  when  they  were  of  a  greater  size  in  the  large  intestine.  This 
observation  is  not  unimportant  at  present,  when  some  theoretical 
physicians  make  the  colon  the  exclusive  seat  of  diarrhoea. 

The  symptoms  of  softening  of  the  stomach,  of  perforation  of  the 
lung,  and  of  its  effect,  pneumo-thorax  (seven  cases  of  which  are  re- 
ported by  the  author),  and  of  ulceration  of  the  epiglottis,  the  larynx 
and  trachea  are  particularly  examined.  We  shall  not  occupy  you 
with  the  symptoms  of  softening  of  the  stomach  and  of  perforation  of 
the  lung,  on  which  subjects  M.  Louis  has  already  presented  to  you 
two  special  Memoirs  ;  we  shall  speak  of  the  other  lesions  only. 

The  patients,  in  whom  the  epiglottis  was  ulcerated,  experienced  a 
fixed  pain  on  a  level  with  the  top  of  the  thyroid  cartilage  or  above  it, 
and  a  difficulty  of  deglutition,  which  was  sometimes  so  great  as  to  cause 
the  rejection  of  liquids  by  the  nose.  A  local  pain  of  greater  or  less 
acuteness,  and  a  complete  loss  of  voice  for  one  or  more  months  were 
the  only  signs  of  ulceration  of  the  larynx.  Ulcers  of  the  trachea, 
however  large,  did  not  usually  produce  any  particular  symptom. 

Lesions  of  the  stomach  gave  rise  to  some  symptoms  which 
have  led  and  can  lead  in  future  to  their  recognition  during  life.  A 
want  of  appetite,  pain  of  the  epigastrium,  and  even  nausea  with 
vomiting  of  bile  have  distinguished  these  lesions.  As  to  vomit- 
ing, which  all  physicians  have  considered  as  excited  exclusively  by 
the  cough,  M.  Louis  thinks  that  it  may  arise  from  this  cause,  espe- 
cially at  the  commencement  of  the  disease  ;  but  he  has  observed  that 
then  patients  have  some  appetite  ;  they  do  not  feel  pain  at  the  epi- 
gastrium, and  can  digest  their  food  with  facility.  By  the  aid  of  these 
signs  he  can  distinguish  with  certainty  sympathetic  vomiting  from 
that  which  is  produced  by  the  lesion  of  the  mucous  membrane  of  the 
stomach. 

As  the  stomach  is  very  often  diseased  in  phthisis,  and  as  phthisis 
is  one  of  the  most  common  diseases,  it  was  at  once  easy  and  inter- 
esting to  know  what  relation  existed  between  the  state  of  the  tongue 


ACADEMY  s    REPORT. 


537 


during  life  and  that  of  the  stomach  after  death,  and  to  test  the  value 
of  the  assertions  which  are  daily  made  on  this  subject.  The  stomach 
appeared  sound  in  19  cases  out  of  97,  in  which  it  was  examined 
with  extreme  attention  ;  in  77  it  presented  various  lesions.  In  9  out 
of  19  in  whom  it  was  sound,  the  tongue  had  been  during  life  more  or 
less  red.  In  one  of  these  latter  cases  the  redness  and  dryness  of  the 
tongue  were  extremely  marked,  and  continue dfr  m  the  patient's 
admission  into  the  hospital  until  death,  which  took  place  thirty-two 
days  after,  and  the  stomach  was  found  perfectly  healthy  in  every  re- 
spect. Of  the  77  other  cases  in  which  the  stomach  presented  either 
a  simple  softening  with  thinning  of  the  mucous  membrane,  or  a  more 
or  less  extensive  redness,  either  mamillated  or  not,  &c.,  the  tongue 
was  red  during  life  in  35  only,  and  in  5  of  these  but  very  slightly  so. 
The  result,  therefore,  is  that  redness  has  been  observed  about  tlie 
same  number  of  times  in  individuals  in  whom  the  stomach  was 
healthy,  and  in  those  in  whom  it  presented  some  serious  lesion. 

The  diagnosis  of  phthisis  is  easy  at  an  advanced  period  ;  every  one 
knows  how  uncertain  it  is  during  the  first  stage,  and  sometimes  fora 
very  long  interval.  M.  Louis  has  particularly  directed  his  attention 
to  determining,  by  the  comparison  of  the  facts  that  have  come  under 
his  observation,  the  signs  by  the  aid  of  which  we  can  at  first  suspect, 
and  afterwards  recognise  this  disease.  A  dry  cough,  which  continues 
for  many  months,  a  shortness  of  breath  easily  brought  on  by  walking 
or  speaking,  pains  of  greater  or  less  acuteness  in  the  back  or  in  the 
sides  of  the  chest,  a  remarkable  diminution  of  flesh  and  strength 
ought  to  create  strong  suspicions  of  the  existence  of  tubercles  in  the 
lungs  ;  if  one  or  more  htemoptyses  occur,  it  is  almost  a  certainty 
that  the  patient  is  phthisical.  Percussion  and  auscultation  are  then 
very  suitable  for  removing  our  doubts;  if  the  sound  of  the  chest  be 
dull  below  one  of  the  clavicles  to  a  small  extent,  if  the  respiratory 
murmur  there  be  more  feeble  and  accompanied  by  some  râles,  these 
two  phenomena  occurring  at  this  point  only,  where  tubercles  generally 
first  develop  themselves,  their  existence  can  no  longer  be  doubted. 
M.  Louis  under  this  head,  relates  the  case  of  a  patient,  in  whom,  by 
means  of  these  signs,  the  disease  was  recognised  seventeen  dayg 
after  the  appearance  of  the  first  symptoms. 
u  3 


53S 


ACADEMY  s    REPORT. 


The  diagnosis  is  usually  easy  in  the  second  period,  when  cavi- 
ties take  the  place  of  tubercles  ;  pectoriloquy  furnishes  a  never- 
failing  sig-n.  It  is  important,  however,  to  remember  that  the  partial 
dilatation  of  some  of  the  bronchia  may  produce  this  phenomenon,  and 
that  in  order  to  form  a  sound  judgment  we  ought  to  connect  with  this 
sign  every  one  that  can  confirm  it.  An  interesting  case  is  reported 
in  support  of  this  wise  precept. 

In  other  articles  of  his  work,  M.  Louis  presents  some  interesting 
views  relative  to  the  duration  of  the  disease,  the  circumstances  under 
which  we  most  commonly  meet  with  it,  the  sudden  deaths,  which  are 
not  very  rare  in  phthisis,  and  which  the  examination  of  the  corpse 
does  not  always  explain.  He  has  remarked  with  respect  to  its  dura- 
tion, that  there  died  in  the  first  year  a  greater  proportion  of  women 
than  of  men.  He  has  found  an  explanation  of  this  difference  in  the 
very  unequal  frequency,  in  the  two  sexes,  of  some  secondary  lesions, 
such  as  the  fatty  degeneration  of  the  liver,  and  the  softening  of  the 
mucous  membrane  of  the  stomach,  which  he  has  met  with  much 
more  frequently  in  women  than  in  men. 

Two  articles  are  devoted  to  latent  and  acute  phthisis.  Five  cases 
catne  under  the  observation  of  M.  Louis,  in  which  there  were  not 
more  than  fifty  days  between  the  appearance  of  the  first  symptoms 
and  the  death  of  the  patients.  In  one  of  these  cases,  death  occurred 
even  on  the  twenty-fourth  day. 

Lastly,  in  a  concluding  chapter,  M.  Louis  has  examined  Avith  the 
facts  before  liim,  the  question  of  the  nature  of  tubercles,  a  question 
so  often  and  so  uselessly  discussed  by  reasoning  and  inference,  and 
he  has  been  led  to  the  conclusion,  that  the  tuberculous  degeneration 
of  the  lungs  is  something  diflTerent  from  inflammation,  or  from  the 
effect  of  inflammation. 

We  shall  here  limit  this  analysis,  in  which  we  have  presented  to 
you  only  the  principal  results  which  the  author  has  deduced  from  his 
observations. 

We  think  that  the  Academy,  whose  special  object  it  is  to  give 
a  useful  direction  to  the  labors  of  physicians,  cannot  aflTord  too  much 
encouragement  to  those  whose  number  is  always  too  small,  who, 
instead  of  abandoning  themselves  with  the  m.ajority  to  theoretical 
discussions,  devote  their  lives  to  the  collection  of  observations  at  the 


academy's  report.  539 

bedside  of  the  sick,  and  search  after  death  for  traces  of  the  disorders 
which  preceded  and  produced  it,  and  from  a  comparison  of  these 
facts  deduce  rigorous  conclusions. 

(Signed,)    BOURDOIS,  ROYER-COLLARD,  CHOMEL,  the  Reporter. 

Read  and  approved  at  the  session  of  the  Section  of  Medicine, 
July  12thj  1825. 

ADELON,  Secretary  of  the  Section. 
A  true  copy,        PARISET,  Perpetual  Secretary. 


INDEX. 


[The  numerals  denote  the  Observations,  the  figures  the  page,  the  capital 
letters  the  sections  of  the  Translator's  Appendix.] 


A. 


Age,     Its  influence  upon  phthisis,  447,  G. 

Aorta.  Frequently  red  internally,  52  ;  almost  always  in  young  subjects^ 
52  ;  its  organic  lesions  common  after  the  age  of  thirty-five  years  ;  its  size 
less  in  phthisis,  but  particularly  in  cancerous  affections  than  in  acute  dis- 
eases, 53  ;  the  cause  of  its  redness  and  of  its  organic  lesions,  55. 

Apoplexy.  Not  found  after  acute  diseases,  which  fact  distinguishes  it 
from  softening  of  the  brain. 

Arachnitis.  Comes  on  sometimes  towards  the  last  periods  of  phthisis, 
140  ;  ventricular  arachnitis,  its  symptoms,  307,  xsiv  ;  sub-arachnoidean 
effusion  complicated  with  partial  softening,  311,  xxv. 

Arachnoid.  Is  the  source  at  times  of  opaque  granulations,  morbid  pro- 
ductions near  the  longitudinal  fissure,  139,  140  ;  contains  sometimes  serous 
fluid  in  its  superior  cavity,  and  the  membrane  situated  under  it  is  frequently 
infiltrated,  140. 

B. 

Bands.  Found  in  tuberculous  excavations,  their  structure,  14,  330, 
xxix. 

Belladonna.    Employed  without  success  in  cough  ;  its  effects,  449. 

Bile.  Oftener  black  and  thick  in  patients  who  died  of  phthisis,  than  in 
those  who  died  of  other  diseases,  and  when  the  liver  is  fatty  than  under  any 
other  circumstances,  112. 

Bladder.     Almost  perfectly  healthy  in  phthisical  patients,  121. 

Blood-letting.    Its  inefficacy  in  many  cases  of  hsemoptysis,  x,  xlii. 


542  INDEX. 

Brain.  Is  sometimes  injected  in  phthisical  patients,  141  ;  wholly  soft- 
ened, 141,  xlix,  1,  or  partially  so,  141,  142  ;  its  partial  and  general  softening 
are  found  almost  exclusively  after  chronic  diseases,  143  ;  sometimes  the  seat 
of  tubercles,  143,  ix  ;  or  of  hydatids,  143,  144,  xxviii. 

Bronchia.  Cannot  be  found  in  tuberculous  cavities,  nor  where  tubercles 
exist,  nor  in  the  grey,  semi-transparent  substance,  35  ;  state  of  their  mucous 
membrane  near  the  cavities  and  crude  tubercles  ;  their  ulcerations,  36, 
sxix,  1. 

c. 

Capsules,  Renal.     Contained  tuberculous  matter  in  two  cases,  117. 

Catechu.     Employed  in  diarrhœa  ;  its  effects,  453. 

Causes  of  Pulmonary  Tubercles.  Result  to  which  we  are  led  by  obser- 
vation, 437  ;  influence  of  sex,  438,  C  ;  that  of  pleurisy  and  pneumonia  not 
proved,  438  to  440,  D  ;  but  supposing  that  this  influence  really  exists,  what 
means  must  we  use  in  order  to  make  it  evident .''  440  ;  influence  of  catarrh 
not  better  demonstrated,  441,  E;  many  observations  of  acute  and  of  latent 
phthisis  prove  directly  that  tubercles  in  the  lungs  are  not  the  effect  of  in- 
flammation, 441,  442,  443  ;  the  condition  of  the  bronchia  confirms  all  these 
facts,  444,  H  ;  influence  of  corsets  is  perhaps  imaginary,  445  ;  what  is  neces- 
sary to  be  done  in  oi-der  definitely  to  determine  the  hereditary  nature  of 
phthisis,  and  to  define  the  exact  limits  of  this  fact,  447  ;  influence  of  age, 
ib.  G  ;  of  various  causes,  G. 

Cavities.  Tuberculous  ;  the  period  at  which  they  are  entirely  empty  ; 
their  structure  when  old  or  recent,  13,  14  ;  communicate  with  the  bron- 
chia, 14  ;  sometimes  traversed  by  bands,  14  ;  they  presuppose  the  destruc- 
tion of  a  portion  of  the  pulmonary  tissue,  14,  15 3  dimensions,  15,  i  ;  char- 
acter of  the  fluid  contents,  21,  22  ;  may  be  filled  with  organized  fibrine,  25, 
ii,  or  contain  a  fragment  of  healthy  lung,  27,  iii  ;  only  one  may  be  formed 
in  a  lung,  and  In  this  there  may  be  no  other  traces  of  tubercles  31,  iii  ;  how 
we  may  prove  such  a  cavity  to  be  tuberculous,  33. 

Chills.  Do  not  occur  in  a  certain  number  of  patients,  191  ;  hour  at 
which  they  usually  return,  191,  192  ;  effect  of  cinchona  upon  them  when 
regular  in  their  recurrence,  192. 

Complications.  Do  not  prevent  the  symptoms  of  the  different  lesions 
from  manifesting  themselves,  245,  xv3  149,  viii  ;  224,  xii  ;  274,  xix. 

Cough.  Variable  in  phthisis,  both  in  force  and  time  of  commencement, 
171  ;  returns  at  times  in  hard  spells,  ib.  :  opium  and  belladonna  employed  for 
it  unsuccessfully,  449,  H. 

Cysts.  Of  a  peculiar  character  developed  in  the  liver.  111,  154,  ix  ; 
fibrous  cysts  containing  hydatids  in  the  liver.  111. 

D. 

Diagnosis.  When  it  is  probable,  201  ;  or  certain  in  the  first  stage  of 
phthisis,  202  to  204,  x  bis.  ;  is  easy  in  the  second  stage  and  depends  then  in 


INDEX.  543 

a  great  measure  upon  the  existence  of  pectoriloquy,  210,  211  ;  importance 
of  percussion  at  this  period  ;  it  alone  is  sufficient  for  the  diagnosis,  210  ;  how 
pectoriloquy  may  he  insufficient  to  indicate  the  existence  of  a  tuberculous 
cavity,  211,  xi  ;  Trans,  note,  203. 

Diarrhœa.  Commences  at  different  epochs,  19-5  ;  the  intestinal  ulcera- 
tions are  small  when  it  commences  late  in  the  disease,  196  ;  they  are  small 
when  it  has  been  long  and  intermittent,  198;  it  seems  at  times  to  be  merely 
an  altered  secretion,  197,  280,  xx. 

Diascordium.     Given  in  diarrhœa  ;  its  effects,  452. 

Duodenum.  Ordinarily  healthy  ;  rarely  ulcerated  ;  its  crypts  are  not 
oftener  enlarged  when  the  liver  is  fatty,  than  when  it  is  healthy,  72. 

Duration  of  phthisis  generally,  169,  170;  in  men  and  in  won)en,  170. 

Dura  Mater.  Is  often  divided  at  its  upper  part,  which  divisions  give 
passage  to  arachnoidean  granulations,  139. 

Dyspnœn.  Its  degree  ;  its  commencement  in  phthisis,  185  ;  exists  some- 
times from  childhood,  185,  186  ;  point  of  the  chest  to  which  it  is  usually 
referred,  186. 

E. 

Emaciation.  Its  commencement,  199  ;  in  some  cases  its  progress  is 
very  rapid  ;  inferences  to  be  drawn  from  it  ;  attacks  all  the  tissues  of  the 
body,  200. 

Emphysema.  Of  the  external  cellular  membrane  rare  in  chronic  dis- 
eases, 134,  vii  ;  emphysema  of  the  liver  still  more  rare,  136,  137,  vii. 

Epiglottis.  Is  frequently  ulcerated  in  phthisical  patients  ;  the  propor- 
tion, 46  ;  these  ulcerations  exist  most  frequently  on  the  laryngeal  face,  47  ; 
and  are  more  .*"requent  in  men  than  in  women  ;  they  are  peculiar  to  phthisi- 
cal patients,  48  ;  their  symptoms,  219,  xii,  xiv  ;  is  sometimes  entirely  de- 
stroyed, 225,  xiii. 

Epiploon.  Contains  at  times  tuberculous  or  semi-transparent  matter, 
135,  vii}  its  mode  of  development,  137. 


Fibre- cartilages  of  the  Trachea.  At  times  solution  of  their  continuity 
in  cases  of  deep  ulceration  of  the  trachea,  249,  251,  xvi. 

Fever.  Origin  and  duration  very  variable  ;  circumstances  which  cause 
its  varieties,  189  ;  its  cause,  189,  190  ;  symptoms  of  continued  fever  in  a 
patient  in  the  last  stages  of  phthisis  and  in  extreme  debility,  184,  185,  x. 

Fever,  Continued.  Scat  of  the  ulcers  of  the  intestine  in  these  cases, 
77. 

Functions.  May  be  deranged  for  a  long  time  without  any  sensible  alter- 
ation in  the  organs  which  perform  them,  for  example,  digestion,  280,  281, 
.322;  exhalation  from  the  skin,  193. 


544  INDEX. 


G. 


Gall- Bladder.     Its  parietes  are  sometimes  thick  and  ulcerated,  113,  114. 

Gastritis.  Anorexia,  even  when  it  lasts  a  long  time,  is  not  sufficient  to 
prove  its  existence  ;  frequent  in  phthisical  patients.     Vide  Stomach. 

Genital  Functions.  Is  it  prohable  that  the  inclination  for  venery  is  in- 
creased in  phthisical  patients,  302. 

Gestation.  May  go  on  regularly  in  phthisis,  305  j  has  it  a  real  influence 
upon  the  cause  of  phthisis,  305, 

Glands.  When  tuberculous  they  are  enlarged,  99  ;  do  not  become 
tuberculous  except  in  phthisical  patients,  106  ;  axillary  glands  become 
tuberculous,  painful,  105,  154,  ix  ;  cervical  glands  tuberculous  in  a  tenth 
part  of  phthisical  patients  ;  cause  of  this  lesion,  105;  lumbar  glands  some- 
times completely  changed  into  tuberculous  matter,  104;  mesenteric  often 
tuberculous,  what  proportion,  100  ;  part  of  the  mesentery  where  they  are 
most  frequently  thus  diseased,  100;  rarely  softened,  101;  causes  of  this 
transformation,  102,  103  ;  sometimes  red  and  swollen  in  phthisical  patients 
without  being  tuberculous,  104;  consequence  of  this  fact,  104;  in  patients 
who  have  died  of  other  chronic  diseases,  106. 

Granulations.  Grey,  semi-transparent  of  the  lungs  follow  the  same 
course  that  tubercles  do,  and  change  more  or  less  rapidly  into  tuberculous 
matter,  5  ;  they  are  the  commencement  of  it,  5  ;  their  arrangement,  the 
îength  of  time  they  occupy  before  becoming  as  large  as  peas,  and  the^part 
of  the  pulmonary  texture  in  which  they  occur,  6. 

Gurgling.  Frequently  heard  over  cavities  at  the  summit  of  the  lungs, 
211 5  indication  of  this  when  combined  with  tracheal  respiration,  215,  216. 

H.         , 

Hœgophony.     Causes,  367,  xxxv. 

Heart.  Generally  small,  rarely  enlarged  in  phthisis  ;  smaller  still  in 
cancerous  affections,  50,  51,  52  ;  sometimes  softened,  50  ;  the  dimensions  of 
the  left  ventricle  vary  much  more  frequently  than  those  of  the  right  ;  in- 
frequency  of  organic  lesions  of  the  heart,  51. 

HcBmoptysis.  Severe  or  slight;  its  frequency;  period  at  which  it  occurs, 
176,  178,  X  ;  when  it  precedes  cough  and  expectoration,  is  it  a  forerunner 
of  tubercles,  or  a  proof  of  their  existence,  176,  177  ;  its  cause  at  the  different 
periods,  177,  178,  1S4,  x  ;  influence  of  sex,  178;  age,  178  ;  constitution, 
179  ;  upon  its  frequency.  Examjiie  of  severe  haemoptysis  occurring  sev- 
eral times,  180,  183,  x,  395,  xlii  ;  its  treatment,  450,  G. 

Hydatids.  Developed  in  a  fibrous  cyst,  which  destroyed  a  lobe  of  the 
liver,  111  ;  very  rarely  found  in  the  brain,  145  to  149,  viii. 


Icterus.     Occurred  several  times  during  one  year  in  a  case  in  which  there 
was  disease  of  the  gall-bladder,  429,  xlix. 


INDEX. 


545 


Inflammation.  Very  common  in  the  later  periods  of  phthisis  and  of 
other  chronic  diseases,  160,  301  ;  dehiUty  predisposes  to  it,  160. 

Intestine,  Small.  Ils  mucous  membrane  when  in  a  healthy  state  ;  its 
structure  ;  number  of  elliptical  patches  observed  in  it,  74,  77  ;  their  dis- 
eases, 78;  its  mucous  membrane  sometimes  softened,  thickened  and  red, 
proportion,  79  ;  tuberculous  or  semi-transparent  granulations  frequent  in 
them,  79,  80  ;  still  more  frequent  are  ulcerations,  81  ;  seat,  size,  form,  color, 
structure  of  the  ulcers,  82,  83;  muscular  membrane  sometimes  thickened,  is 
at  times  destroyed  over  them,  83,  84,  iv  ;  cause  of  the  ulcerations,  93  ;  con- 
dition of  the  small  intestine  after  other  chronic  diseases,  90. 

Intestine,  Large.  Its  mucous  membrane  often  red,  .softened  and  thick- 
ened, proportion,  91,  92  ;  cause  of  this  softening,  93,  94  ;  period  at  which 
it  occurs,  94  ;  submucous  cellular  membrane  frequently  thickened  and 
white  when  the  mucous  is  softened  ;  cause  of  this  thickening,  93  ;  its  ulcer- 
ations a  little  less  frequent  than  those  of  the  small  intestine,  95  ;  their  di- 
mensions, 87,  95,  iv,  224,  xii  ;  their  frequency  in  the  different  parts  of  the 
intestine,  95;  their  form,  color  and  structure,  95,96;  causes,  98  ;  tubercu- 
lous granulations  are  much  more  frequent  there  than  in  the  small  intestine, 
94;  they  are  never  found  in  subjects  who  have  died  of  other  chronic  affec- 
tions than  phthisis,  99  ;  condition  of  the  large  intestine  in  consequence  of 
these  affections,  lb. 


K 


Kidneys.     Sometimes  in  phthisical  patients  have  cysts  and  tubercles  in 
them,  117, 118,  v. 


L. 


Larynx.  Frequency  of  ulcers  in  it,  their  situation  and  extent,  46  ;  symp- 
toms, 237  ;  peculiar  to  phthisis,  48. 

Lesions  peculiar  to  -phthisical  subjects.  Lesions  which  are  common  to 
them  with  those  who  die  of  other  chronic  diseases  ;  their  origin,  general 
causes,  159  to  162. 

Liver,  Often  fatty  in  phthisical  patients,  especially  in  women,  in  what 
proportion,  107  ;  fatty  change  may  come  on  very  rapidly,  109  ;  no  peculiar 
symptom  marks  it,  110.  Liver  sometimes  has  cysts  of  a  peculiar  character 
in  it.  111  ;  its  left  lobe  may  be  destroyed  by  a  fibrous  cyst  containing  hy- 
datids, 111;  its  consistence  is  very  variable.  111,  112;  it  is  sometimes 
affected  with  a  very  marked  emphysema,  112,  135,  vii. 

Lungs.  Do  the  wrinkled  depressions,  found  sometimes  at  the  apex,  cor- 
respond to  fixed  lesions  ?  35  ;  their  apex  is  at  times  enveloped  with  a  kind  of 
semi-cartilaginous  covering,  which  is  thick  in  a  case  of  a  very  large  cav- 
ity, 15 

w  3 


546  INDEX. 


M. 

Membranes.  Muscular  membrane  of  the  stomach  transformed  over  a 
small  space  to  a  semi-cartilaginous  substance,  291,  xxii. 

Membranes,  Serous.  All  of  them  are  more  or  less  subject  to  an  effusion 
of  serous  fluid  in  phthisical  patients,  159. 

Menstruation.  Sometimes  continues  to  the  very  last  periods  of  phthisis, 
303;  most  common  period  of  its  suppression,  304  j  causes  which  retard  or 
accelerate  it,  304,  305. 

Mesentery.     Wholly  tuberculous,  297,  xxiii.     See  Glands. 

Mesocolon,  Mesorectum.  Tuberculous  and  semitransparent  substance  in 
lamina,  135,  vii. 


o. 


Œdema  of  the  Glottis.  Rare  in  phthisical  subjects  who  have  ulcera- 
tions in  the  larynx,  48  ;  what  that  indicates,  421,  422,  xlvi. 

Œdema  of  the  Legs.  Rare  in  phthisical  patients,  201  ;  example  of  one 
of  those  cases  of  œdema  which  had  been  very  considerable  ;  obstruction  of 
the  crural  veins  with  layers  of  fibrine,  thickening  of  their  parietes,  30. 

Œsophagus.  Rarely  ulcerated  in  phthisis,  57  ;  often  deprived  of  its 
epidermis  ;  its  parietes  sometimes  thinned  and  softened  near  the  cardia,  58  j 
remnants  of  a  kind  of  membrane  upon  its  surface,  57,  337,  339,  xxx  ;  symp- 
toms which  depend  upon  it,  335,  339. 

Opium.  Inefficacious  in  cases  of  pains  from  thinning  and  softening  of 
the  mucous  membrane  of  the  stomach,  255  ;  administered  likewise  without 
effect  in  diarrhœa,  during  the  last  days  of  life  of  phthisical  patients,  453. 

P. 

Pains  of  the  chest  in  Phthisis.  Degree,  frequency,  situation,  186,  187  j. 
cause,  187, 188  ;  cases  in  which  they  do  not  exist,  188  ;  when  the  disease 
goes  on  rapidly,  368,  372. 

Pectoriloquy.  Time  of  ^occurrence,  1G8  ;  must  be  accompanied  with 
other  signs  in  order  for  it  to  indicate  certainly  the  existence  of  phthisis,  212, 
xi.  215. 

Percussion.  Importance  for  the  diagnosis  of  phthisis  in  its  first  and  sec- 
ond periods,  210.     Vide  Perforation. 

Perforation  of  the  lungs  in  Phthisis.  Its  varieties,  379  5  perforation  not 
communicating  with  the  bronchia,  383,  xxxix,  394,  xhi  ;  side  of  the  chest 
most  usually  affected  by  it  ;  part  of  the  lungs  where  it  occurs,  411  ;  number 
of  perforations  in  the  same  subject;  reason  why  they  are  not  more  frequent, 
412;  age  of  the  patients,  413  ;  symptoms  of ,  402  5  may  be  suspected  à^norir 
402;  pain  may  be  absent  and  yet  the  diagnosis  may  not  be  impossible,  403, 
xliv  ;  how  the  rational  symptoms  are  confirmed  by  auscultation  and  perçus- 


INDEX.  547 

cussion,  407,  408;  do  the  rational  symptoms  always  take  place?  use  of  aus- 
cultation and  percussion  when  they  are  slight,  409  ;  duration  of  life  after 
perforation,  410. 

Peritoneum.  Frequently  the  seat  of  an  effusion  of  serous  fluid  in  phthis- 
ical patients,  130  ;  miliary  granulations  on  its  surface,  their  nature,  131. 
Tuberculous  patches  between  the  folds  of  a  false  membrane  effused  upon  all 
the  free  surface,  131,  345,  xxxiij  old  adhesions,  131  ;  its  condition  in  con- 
sequence of  chronic  diseases  different  from  phthisis,  138. 

Peritonitis,  Acute.     Occurs  sometimes  during  the  last  days  of  life,  131. 

Pia  mater.  Sometimes  injected  more  or  less  in  phthisical  patients  as 
after  other  chronic  diseases,  141,  142. 

Pharynx.  Rarely  ulcerated  in  phthisis,  57,  227,  xiii  ;  condition  after 
other  chronic  diseases,  58. 

Phthisis.  What  it  consists  of,  3  ;  two  periods,  first  before,  second  after 
the  softening  and  evacuation ,  of  the  tuberculous  matter,  general  descrip- 
tion, 165  to  171  ;  duration  in  114  persons,  169  3  course  more  rapid  in  women 
than  in  men,  170  ;  why  so  :  proportion  between  it  and  other  diseases  which 
prove  mortal  either  from  their  nature  or  by  accident,  170. 

Phthisis,  Acute.  Example,  death  on  35th  day,  368,  xxxvi;  can  we  re- 
cognise it  ?  Example  of  a  remittent  acute  case,  368,  xxxvi  ;  its  diagnosis  in 
the  first  period  in  which  there  is  much  doubt,  372  ;  produces  the  same  sec- 
ondary disorders  that  chronic  cases  do,  373  ;  are  all  ages  liable  to  it?  374. 

Phthisis,  Latent.  Cases  of  one  latent  a  year,  six  months,  &c.,  xxvii, 
xxviii,  &c.  The  facts  belonging  to  tMs  species  of  phthisis  are  naturally 
divided  into  two  classes,  350  ;  diagnosis,  350,  351  ;  phthisis  latent  like  all 
other  diseases  over  those  which  are  acute,  351  ;  are  any  causes  to  be  as- 
signed for  this  latent  state  of  phthisis  ?  351,  352. 

PleurcB.  Adhesions  much  more  frequent  than  in  other  chronic  diseases, 
39  J  cause  and  nature  of  these  adhesions,  40,  41  ;  effusion  of  serous  fluid 
frequent  into  their  cavity,  41  ;  false  membrane  covering  the  right  pleura  in 
a  great  measure  tuberculous,  258,  262.  xvii. 

Pregnancy.     Capable  of  retarding  consumption  ?  305. 

Prostate.     Sometimes  tuberculous  in  phthisis,  122  and  vi,  127. 

Pulmonary  Artery.  Its  arrangement  in  the  lungs  of  phthisical  patients, 
8,  331,  xxix. 

Pneumonia,  Acute.  Generally  curable  in  phthisis,  218  ;  frequent  at  the 
end  of  phthisis  and  other  chronic  affections,  37,  3S  ;  symptoms,  217;  period 
of  its  commencement,  217. 

Pneumonia,  Chronic.  Anatomical  characteristics  ;  exists  sometimes  at 
the  summit  of  the  lungs  in  phthisical  patients,  11. 


R. 


Rectum.    Ulcerations,  96  ;  symptoms  of  them,  199. 
Respiration,  Tracheal.    Heard   over  cavities,  168. 


548 


INDEX. 


S. 


Seltzer  Water.  Momentary  relief  from  it  of  the  pains  caused  by  the 
softening  and  thinning  of  the  mucous  membrane  of  the  stomach,  255. 

Semi-transparent  grey  substance.  Frequent  in  the  lungs  in  phthisis, 
7  5  changes  into  tubercles,  7}  sometimes  found  in  other  parts,  135,  vii} 
rarely  vessels  in  it,  8,  331,  xxixj  sometimes  arranged  in  zones,  420, 
xlvi. 

Spleen.  Sometimes  tuberculous  in  phthisis,  115  ;  in  one  case  had  in  it  an 
accidental  tissue  of  another  nature,  116  ;  sometimes  very  small  ;  variable 
consistence,  116;  size  independent  of  the  circulation,  116;  sometimes  cov- 
ered with  a  tuberculous  false  membrane,  260,  xvii  ;  its  lesions  in  conse- 
quence of  other  diseases,  116. 

Sputa.  Chai'actei-s  and  differences  in  the  first  and  second  periods  of 
phthisis,  172,  173;  their  appearance  during  the  last  days  of  life,  173;  their 
quantity,  173;  influence  of  regimen  upon  their  appearance,  174;  their  two- 
fold source  in  the  second  period  of  phthisis,  174. 

Stomach.  In  many  cases  very  large,  and  had  its  position  altered  oftener 
in  phthisical  patients  than  in  those  who  died  of  other  chronic  diseases,  59; 
mucous  membrane  was  frequently  and  more  seriously  diseased  in  phthisis 
than  in  other  affections  ;  tables  proving  this  assertion,  70,  71  ;  thinning  and 
softening  of  the  mucous  membrane  of  the  stomach,  60;  different  aspects  of 
this  lesion,  61,  62;  its  causes;  proportion  of  its  occurrence  in  men  and 
women,  63;  symptoms  of  it,  their  origin,  progress  and  duration,  254  ;  rarely 
fail  to  occur,  256;  when  marked  they  are  superior  to  all  the  rest,  257,  xvii; 
inflammation  of  the  mucous  membrane  of  the  anterior  face,  64;  proportion 
of  cases  in  which  this  is  met  with,  64  ;  influence  of  the  hver  upon  it,  65  ; 
symptoms,  263;  why  suspect  its  liuiited  nature,  263,  xviii;  redness  and 
softening  of  the  mucous  membrane  limited  to  the  great  cul-de-sac,  65  ;  pro- 
portion of  cases  in  which  this  lesion  is  met  with,  65  ;  its  nature,  the  period 
of  its  development,  66  ;  its  symptoms,  270  ;  observed  rarely,  270,  xix  ;  sim- 
pie  ulcerations  of  the  mucous  membrane,  68  ;  syuiptoms,  275,  xx  ;  mamil- 
lated  state,  greyish  color  of  mucous  membrane,  nature  of  this  lesion,  68; 
has  no  well  marked  symptoms  in  phthisical  patients,  279;  digestive  func- 
tions not  commonly  altered  when  the  mucous  membrane  is  well,  280,  281  ; 
Other  lesions  of  this  membrane  ;  universal  redness  without  change  of  struc- 
ture, 2S1  ;  large  nipple  like  processes  ;  pus  under  the  mucous  membrane  ; 
imperfect  cicatrization,  70,  xxi  ;  muscular  membrane  changed  into  semi- 
cartilaginous  substance,  268,  xxii. 

Sudamina.     Not  common  in  perspirations  of  phthisis,  193. 

Sudden  death.  Sometimes  accounted  for  in  phthiais  by  the  state  of  the 
organs  after  death,  414.  xlv,  xlvi  ;  at  other  times  impossible,  xlvii,  xlviii; 
occurred  in  two  persons  in  whom  the  brain  was  throughout  very  much  soft- 
ened, 429,  xlix,  1. 

Smi:uts.  Fi-equent  in  phthisis,  192;  not  inversely  as  (he  diarrhœa,  192; 
cause  of  them  in  phthisical  patients,  193. 


INDEX.  549 


T. 

Thickening.    Very  important  to  be  noted  in  all  cases,  93. 

Thirst.  In  how  many  cases  absent  5  symptoms  and  lesions  with  which 
it  coincides,  194. 

Tiiikling,  Metallic.  Heard  sometimes  over  large  cavities,  216,  217,  i, 
xxviii  ;  mode  of  distinguishing  this  from  the  tinkling  which  occurs  in  per- 
foration of  the  pulmonary  texture,  216  5  condition  of  the  tinkling  in  this  last 
case,  409. 

Tongue.  Color  in  different  states  of  the  mucous  membrane,  293,  294  ; 
cases  in  which  it  remained  more  or  less  deeply  red,  and  afterwards  became 
dry  while  the  mucous  membrane  of  the  stomach  was  perfectly  healthy 
295,  xxiii  ;  its  importance  in  pathology,  2  8  ;  membranous  exudation  on  it, 
surface  nearly  equally  frequent  in  all  conditions  of  the  stomach  5  cause  and 
nature  of  this  exudation,  299,  300. 

Trachea.  Ulcers  very  frequent  and  occupy  at  times  all  the  fleshy  por- 
tion, 43,  44  ;  their  cause,  44,  45  ;  their  symptoms,  239,  240,  xv. 

Treatment.  When  no  fever,  and  when  more  or  less  severe,  448  ;  when 
phthisis  is  somewhat  acute,  449  j  cough  not  very  bad,  449  ;  symptoms  of 
pleurisy,  449  ;  pneumonia,  450  ;  severe  haemoptysis,  450  ;  ulcers  of  the 
larynx  ;  copious  perspiration,  pains  at  the  epigastrium  and  vomiting,  451 5 
severe  diarrhœa,  452,  G. 

Tuber  .annulare.     Tuberculous,  vi,  125. 

Tubercles.  Their  qualities,  laws  of  development,  4,  5  ;  exist  almost  al- 
ways in  both  lungs,  6,  10  5  so  ten  at  various  epochs  gradually,  from  the 
apex  to  the. base,  rarely  all  at  once,  12,  13  5  not  entirely  emptied  before  the 
third  month  from  their  commencement,  13;  same  degree  of  development 
out  of  the  lungs  every  where  3  what  this  circumstance  proves,  155,  156,  vi, 
ix,  262,  xvii,  256;  peculiar  to  phthisis  161. 

Tubercles,  Encysted,  342,  xxxi. 

u. 

Ulcerations  of  the  Stomach,  Epiglottis,  fyc.  Sfc.  (Vide  these  words)  ; 
what  they  have  in  common,  161. 

Uterus.  Tuberculous,  129,  xxxii  ;  size  and  condition  in  those  who  die  of 
other  diseases,  130  ;  inflamed  alter  delivery,  xxxvii. 


Vasa  Deferentia.    Tuberculous,  122,  vi;  causes  of  this  lesion,  128. 

Ventricles  of  the  Brain.  Frequent  serous  eifusion  towards  the  end  of 
chronic  diseases,  141,  142. 

VesiculcB  Séminales.  Tuberculous,  122,  128,  vi  ;  cause  of  this  lesion, 
128. 


550  INDEX. 

Vomiting.  Depends  sometimes  on  the  cough  merely  ;  ordinarily  on  the 
bad  condition  of  the  mucous  membrane  of  the  stomach  ;  mode  of  distinguish- 
ing these  two  cases,  281  to  283. 

w. 

Women.  More  liable  to  phthisis  than  men,  and  to  grave  affections  of  the 
mucous  membrane  of  the  stomach,  63,  65  ;  to  the  fatty  stale  of  the  fiver, 
109  ;  less  exposed  to  ulcers  of  the  epiglottis,  larynx  and  trachea,  47  ;  greater 
mortality  among  them  than  among  men  during  the  first  year  of  phthisis, 
170, 


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